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Unroe KT, Ersek M, Tu W, Floyd A, Becker T, Trimmer J, Lamie J, Cagle J. Using Palliative Leaders in Facilities to Transform Care for People with Alzheimer's Disease (UPLIFT-AD): protocol of a palliative care clinical trial in nursing homes. BMC Palliat Care 2023; 22:105. [PMID: 37496001 PMCID: PMC10369841 DOI: 10.1186/s12904-023-01226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Palliative care is an effective model of care focused on maximizing quality of life and relieving the suffering of people with serious illnesses, including dementia. Evidence shows that many people receiving care in nursing homes are eligible for and would benefit from palliative care services. Yet, palliative care is not consistently available in nursing home settings. There is a need to test pragmatic strategies to implement palliative care programs in nursing homes. METHODS/DESIGN The UPLIFT-AD (Utilizing Palliative Leaders in Facilities to Transform care for people with Alzheimer's Disease) study is a pragmatic stepped wedge trial in 16 nursing homes in Maryland and Indiana, testing the effectiveness of the intervention while assessing its implementation. The proposed intervention is a palliative care program, including 1) training at least two facility staff as Palliative Care Leads, 2) training for all staff in general principles of palliative care, 3) structured screening for palliative care needs, and 4) on-site specialty palliative care consultations for a one-year intervention period. All residents with at least moderate cognitive impairment, present in the facility for at least 30 days, and not on hospice at baseline are considered eligible. Opt-out consent is obtained from legal decision-makers. Outcome assessments measuring symptoms and quality of care are obtained from staff and family proxy respondents at four time points: pre-implementation (baseline), six months after implementation, at 12 months (conclusion of implementation), and six months after the end of implementation. Palliative care attitudes and practices are assessed through surveys of frontline nursing home staff both pre- and post-implementation. Qualitative and quantitative implementation data, including fidelity assessments and interviews with Palliative Care Leads, are also collected. The study will follow the Declaration of Helsinki. DISCUSSION This trial assesses the implementation and effectiveness of a robust palliative care intervention for residents with moderate-to-advanced cognitive impairment in 16 diverse nursing homes. The intervention represents an innovative, pragmatic approach that includes both internal capacity-building of frontline nursing home staff, and support from external palliative care specialty consultants. TRIAL REGISTRATION The project is registered on ClinicalTrials.gov: NCT04520698.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA.
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Wanzhu Tu
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA
- Department of Biostatistics, Indiana University, Indianapolis, IN, 46202, USA
| | | | - Todd Becker
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
| | - Jessica Trimmer
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
| | - Jodi Lamie
- Regenstrief Institute, Inc, Indianapolis, IN, 46202, USA
| | - John Cagle
- University of Maryland School of Social Work, Baltimore, MD, 21201, USA
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The Quebec Observatory on End-of-Life Care for People with Dementia: Implementation and Preliminary Findings. Can J Aging 2022; 41:631-640. [PMID: 35137682 DOI: 10.1017/s0714980821000659] [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: 12/16/2022] Open
Abstract
Most Canadians with dementia die in long-term care (LTC) facilities. No data are routinely collected in Canada on the quality of end-of-life care provided to this vulnerable population, leading to significant knowledge gaps. The Quebec Observatory on End-of-Life Care for People with Dementia was created to address these gaps. The Observatory is a research infrastructure designed to support the collection of data needed to better understand, and subsequently enhance, care quality for residents dying with dementia. This article reports on the main steps involved in setting up the Observatory, as well as a pilot study that involved 172 residents with dementia who died between 2016 and 2018 in one of 13 participating facilities. It describes the data gathered, methodological changes that were made along the way, feedback from participating facilities, and future developments of the Observatory.
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Measuring relatives' perceptions of end-of-life communication with physicians in five countries: a psychometric analysis. Eur J Ageing 2022; 19:1561-1570. [PMID: 36692786 PMCID: PMC9729495 DOI: 10.1007/s10433-022-00742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
The Family Perceptions of Physician-Family Caregiver Communication scale (FPPFC) was developed to assess quality of physician-family end-of-life communication in nursing homes. However, its validity has been tested only in the USA and the Netherlands. The aim of this paper is to evaluate the FPPFC construct validity and its reliability, as well as the psychometric characteristics of the items comprising the scale. Data were collected in cross-sectional study in Belgium, Finland, Italy, the Netherlands and Poland. The factorial structure was tested in confirmatory factor analysis. Item parameters were obtained using an item response theory model. Participants were 737 relatives of nursing home residents who died up to 3 months prior to the study. In general, the FPPFC scale proved to be a unidimensional and reliable measure of the perceived quality of physician-family communication in nursing home settings in all five countries. Nevertheless, we found unsatisfactory fit to the data with a confirmatory model. An item that referred to advance care planning performed less well in Poland and Italy than in the Northern European countries. In the item analysis, we found that with no loss of reliability and with increased coherency of the item content across countries, the full 7-item version can be shortened to a 4-item version, which may be more appropriate for international studies. Therefore, we recommend use of the brief 4-item FPPFC version by nursing home managers and professionals as an evaluation tool, and by researchers for their studies as these four items confer the same meaning across countries.
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Kroenke K, Gao S, Mosesso KM, Hickman SE, Holtz LR, Torke AM, Johnson NM, Sachs GA. Prevalence and Predictors of Symptoms in Persons with Advanced Dementia Living in the Community. J Palliat Med 2022; 25:1376-1385. [PMID: 35357951 PMCID: PMC9492904 DOI: 10.1089/jpm.2021.0402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Behavioral, psychological, and physical symptoms are prevalent in advanced dementia, as well as major contributors to poor quality of life, health care costs, caregiver burden, and nursing home placement. Objectives: To determine the frequency and severity of symptoms in persons with advanced dementia living in the community, as well as the association between symptoms and satisfaction with care, and the identification of factors associated with symptom burden. Design: Baseline data from a clinical trial testing the effectiveness of collaborative care home-based management for patients with advanced dementia. Setting/Subjects: Two hundred and one patient-caregiver dyads from an urban area in the United States, who were still residing in the community. Measurements: Caregivers completed the Symptom Management in End-of-Life Dementia (SM-EOLD) and Satisfaction with Care in End-of-Life Dementia (SWC-EOLD) scales. Results: Patients' mean age was 83.1; 67.7% were women, and most were either White (50.2%) or African American (43.8%). Most (88.1%) had severe dementia (Functional Assessment Staging Tool [FAST] stage 6 or 7). SM-EOLD mean score was 29.3 (on 0-45 scale) and SWC-EOLD score was 32.6 (on 10-40 scale). Pain, agitation, anxiety, and resistiveness to care were present at least weekly in ≥40% of patients. Multivariable linear regression modeling showed that higher neuropsychiatric symptom severity (assessed by the Neuropsychiatric Inventory), increased caregiver strain, and higher medical comorbidity were all independently associated with increased symptom burden. Satisfaction with care was high and had only a modest correlation (r = 0.20) with symptom burden. Conclusions: Community-dwelling patients with advanced dementia and their caregivers may benefit from home-based palliative care interventions to identify and manage burdensome symptoms.
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Affiliation(s)
- Kurt Kroenke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelly M. Mosesso
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan E. Hickman
- Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Laura R. Holtz
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M. Torke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Nina M. Johnson
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Greg A. Sachs
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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5
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Zumstein N, Yamada K, Eicher S, Theill N, Geschwindner H, Wolf H, Riese F. The German version of the Mini Suffering State Examination (MSSE) for people with advanced dementia living in nursing homes. BMC Geriatr 2022; 22:595. [PMID: 35850694 PMCID: PMC9290288 DOI: 10.1186/s12877-022-03268-0] [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: 11/15/2021] [Accepted: 07/05/2022] [Indexed: 12/02/2022] Open
Abstract
Background The Mini Suffering State Examination (MSSE) has been explicitly recommended to assess suffering in dementia patients. This study aimed to develop a German version of the MSSE and assess its psychometric properties involving people with advanced dementia (PAD) in a nursing home setting. Methods The MSSE was translated into German, and 95 primary nurses administered it cross-sectionally to 124 PAD in Zurich, Switzerland. The psychometric properties of the German MSSE version were calculated for this population. Results The mean age of the PAD was 83.3 years (SD = 9.1, range = 55–102 years), and 98 of them (79.0%) were women. The Kuder-Richardson Formula 20 coefficient for the entire scale (0.58), the eight items relating to objective health conditions (0.39), and the professional and family estimation of the patient’s suffering (0.64) indicated low internal consistency. A confirmatory factor analysis indicated an unsatisfactory fit to a one-factor structure, with a comparative fit index and root mean square error of approximation of 0.71 and 0.08, respectively, and a Tucker–Lewis index of 0.64. The MSSE total score was significantly but moderately correlated with the total scores of the Symptom Management–End-of-Life with Dementia (SM-EOLD) scale (Pearson’s correlation coefficient (r) = -0.44; p < 0.05), the physical suffering scores (r = 0.41; p < 0.05), and the psychological suffering scores (r = 0.55; p < 0.05). Conclusions The German version of the MSSE questionnaire did not perform well in the nursing home setting involving PAD. The instrument had low internal consistency, doubtful validity, and could not discriminate between suffering and other distressing symptoms. We do not recommend its use in this population.
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Affiliation(s)
- Naomi Zumstein
- University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Andreasstrasse 15, 8050, Zurich, Switzerland. .,Department of Anthropology, McGill University, 855 Sherbrooke Street West, Montreal, QC, H3A 2T7, Canada.
| | - Keiko Yamada
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, QC, H3A 1G1, Canada.,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Stefanie Eicher
- University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Andreasstrasse 15, 8050, Zurich, Switzerland.,Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Nathan Theill
- University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Andreasstrasse 15, 8050, Zurich, Switzerland.,Division of Geriatric Psychiatry, University Hospital of Psychiatry, Lenggstr. 31, 8032, Zurich, Switzerland
| | - Heike Geschwindner
- City of Zurich Nursing Homes, Eggbühlstrasse 23, 8050, Zurich, Switzerland
| | - Henrike Wolf
- Psychiatrische Dienste Graubünden, Ambulatory Psychiatric Services, Piazza Paracelsus 2, 7500, St. Moritz, Switzerland
| | - Florian Riese
- University Research Priority Program "Dynamics of Healthy Aging", University of Zurich, Andreasstrasse 15, 8050, Zurich, Switzerland.,Division of Geriatric Psychiatry, University Hospital of Psychiatry, Lenggstr. 31, 8032, Zurich, Switzerland
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6
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Vandenbogaerde I, De Vleminck A, van der Heide A, Deliens L, Van den Block L, Smets T. Quality of end-of-life nursing home care in dementia: relatives' perceptions. BMJ Support Palliat Care 2022:bmjspcare-2021-003497. [PMID: 35710707 DOI: 10.1136/bmjspcare-2021-003497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Only a few studies have investigated the quality of end-of-life care provided to nursing home residents with dementia as perceived by their relatives. We aim to investigate the quality of end-of-life care as perceived by relatives and to investigate which characteristics of nursing home residents with dementia, their relatives and the care they received are associated with the evaluation the quality of end-of-life care as perceived by the relatives. METHODS Data used were from two cross-sectional studies performed in Flanders in 2010 and 2015. Questionnaires were sent to bereaved relatives of nursing home residents with dementia and 208 questionnaires were returned. The quality of end-of-life care as perceived by the relatives was measured with the End-of-Life with Dementia-Satisfaction With Care scale (scores ranging 10-40). RESULTS In total, 208 (response rate2010: 51.05%, response rate2015=60.65%) bereaved relatives responded to the questionnaire. The quality of end-of-life care as perceived by them was positively associated with the nursing home resident being male (b=1.78, p<0.05), relatives receiving information on palliative care (b=2.92, p<0.01) and relatives receiving information about medical care from care providers (b=2.22, p<0.01). CONCLUSION This study suggests that relatives need to be well informed about palliative and medical care. Future end-of-life care interventions in nursing homes should focus on how to increase the information exchange and communication between nursing home staff and relatives.
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Affiliation(s)
- Isabel Vandenbogaerde
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Aline De Vleminck
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Luc Deliens
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Lieve Van den Block
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Tinne Smets
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
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Which has more influence on a family's assessment of the quality of dying of their long-term care resident with dementia: Frequency of symptoms or quality of communication with healthcare team? Palliat Support Care 2022; 21:438-444. [PMID: 35346414 DOI: 10.1017/s1478951522000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Symptoms present at the end of life and the quality of communication with the healthcare team have both been shown to impact family assessments of the quality of dying of their loved one with dementia. However, the relative contributions of these two factors to family assessments have not yet been investigated. To address this knowledge gap, we explored which of these two factors has more influence on family assessments of the quality of dying of long-term care (LTC) residents with dementia. METHOD This is a secondary analysis of a mortality follow-back study. Ninety-four family members of LTC residents who had died with dementia assessed the quality of dying (very good or not very good), the frequency of symptoms, and the quality of communication with the healthcare team using a self-administered questionnaire mailed 1 month after the resident's death. Logistic regression analyses were performed to determine the relative contributions of the two independent variables of primary interest (frequency of symptoms and quality of communication) to the families' assessments of the quality of dying. RESULTS Multivariate analyses revealed that the quality of communication with the healthcare team was closely linked to the quality of dying (p = 0.009, OR = 1.34, 95% CI = 1.09-1.65), whereas the frequency of symptoms was not (p = 0.142, OR = 1.05, 95% CI = 0.98-1.11) after controlling for potential confounders. SIGNIFICANCE OF RESULTS Our findings show that healthcare providers' ability to engage in the end-of-life conversations with families outweighs the frequency of symptoms in family assessments of the quality of dying of their relative with dementia. Enhancing healthcare providers' ability to communicate with families about the end-of-life care could improve families' perceptions of the quality of dying of their relative with dementia and, consequently, ease their grieving process.
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Klapwijk MS, Bolt SR, Boogaard JA, Ten Koppel M, Gijsberts MJH, van Leussen C, The BAM, Meijers JM, Schols JM, Pasman HRW, Onwuteaka-Philipsen BD, Deliens L, Van den Block L, Mertens B, de Vet HC, Caljouw MA, Achterberg WP, van der Steen JT. Trends in quality of care and dying perceived by family caregivers of nursing home residents with dementia 2005-2019. Palliat Med 2021; 35:1951-1960. [PMID: 34455856 PMCID: PMC8637361 DOI: 10.1177/02692163211030831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Dementia palliative care is increasingly subject of research and practice improvement initiatives. AIM To assess any changes over time in the evaluation of quality of care and quality of dying with dementia by family caregivers. DESIGN Combined analysis of eight studies with bereaved family caregivers' evaluations 2005-2019. SETTING/PARTICIPANTS Family caregivers of nursing home residents with dementia in the Netherlands (n = 1189) completed the End-of-Life in Dementia Satisfaction With Care (EOLD-SWC; quality of care) and Comfort Assessment in Dying (EOLD-CAD, four subscales; quality of dying) instruments. Changes in scores over time were analysed using mixed models with random effects for season and facility and adjustment for demographics, prospective design and urbanised region. RESULTS The mean total EOLD-SWC score was 33.40 (SD 5.08) and increased by 0.148 points per year (95% CI, 0.052-0.244; adjusted 0.170 points 95% CI, 0.055-0.258). The mean total EOLD-CAD score was 30.80 (SD 5.76) and, unadjusted, there was a trend of decreasing quality of dying over time of -0.175 points (95% CI, -0.291 to -0.058) per year increment. With adjustment, the trend was not significant (-0.070 EOLD-CAD total score points, 95% CI, -0.205 to 0.065) and only the EOLD-CAD subscale 'Well being' decreased. CONCLUSION We identified divergent trends over 14 years of increased quality of care, while quality of dying did not increase and well-being in dying decreased. Further research is needed on what well-being in dying means to family. Quality improvement requires continued efforts to treat symptoms in dying with dementia.
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Affiliation(s)
- Maartje S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Huis op de Waard, Marente, Leiden, The Netherlands
| | - Sascha R Bolt
- Department of Health Services Research, Faculty of Health Medicine and Lifesciences, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Jannie A Boogaard
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maud Ten Koppel
- Zorginstituut Nederland, Diemen, North Holland, The Netherlands
| | - Marie-José He Gijsberts
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | | | - B Anne-Mei The
- Tao of Care, Amsterdam, The Netherlands.,Department Sociology, Faculty of Social Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith Mm Meijers
- Department of Health Services Research, Faculty of Health Medicine and Lifesciences, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands.,Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Jos Mga Schols
- Department of Health Services Research, Faculty of Health Medicine and Lifesciences, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | | | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Bart Mertens
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Henrica Cw de Vet
- Department of Epidemiology and Data Science, Amsterdam UMC, Location VU University Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Monique Aa Caljouw
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
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Roβmeier C, Hartmann J, Riedl L, Dorn B, Fischer J, Hartmann F, Egert-Schwender S, Kehl V, Schneider-Schelte H, Jox RJ, Dinkel A, Diehl-Schmid J. How Do Persons with Young and Late Onset Dementia Die? J Alzheimers Dis 2021; 81:843-852. [PMID: 33843681 PMCID: PMC8203230 DOI: 10.3233/jad-210046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND End of life symptoms and symptom management as well as the quality of dying (QoD) of persons with advanced dementia (PWAD) have not yet been systematically studied in Germany. OBJECTIVE 1) To investigate symptoms, treatment and care at the end of life, advance care planning, and circumstances of death of recently deceased PWAD; 2) To determine whether there are differences between young and late onset dementia (YOD and LOD). METHODS The study was performed in the context of the project EPYLOGE (IssuEs in Palliative care for persons in advanced and terminal stages of Young-onset and Late-Onset dementia in Germany). Closest relatives of recently deceased patients with advanced YOD (N = 46) and LOD (N = 54) living at home or in long term care were interviewed. RESULTS Circumstances of death, symptoms, and treatment appeared to be similar between YOD and LOD, except that persons with LOD had significantly more somatic comorbidities and were admitted to hospital in the last three months of life more often than persons with LOD. At end of life, 60% of PWAD appeared to be "at peace". Difficulty swallowing, gurgling, shortness of breath, and discomfort were observed most frequently. Large interindividual differences in suffering and QoD were present. Determinants of QoD were not identified. CONCLUSION Our findings suggest that low QoD was caused by inadequate recognition and/or insufficient treatment of burdensome physical and emotional symptoms. PWADs' needs should be assessed regularly, and strategies focusing on treatment and implementing support for both the patient and caregiver must be established.
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Affiliation(s)
- Carola Roβmeier
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Julia Hartmann
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Lina Riedl
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Bianca Dorn
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Julia Fischer
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Florentine Hartmann
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Silvia Egert-Schwender
- Technical University of Munich, School of Medicine, Münchner Studienzentrum, Munich, Germany
| | - Victoria Kehl
- Technical University of Munich, School of Medicine, Institute of Medical Informatics, Statistics and Epidemiology, Munich, Germany
| | | | - Ralf J Jox
- Palliative and Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Andreas Dinkel
- Technical University of Munich, School of Medicine, Department of Psychosomatic Medicine and Psychotherapy, Munich, Germany
| | - Janine Diehl-Schmid
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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10
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van der Steen JT, Westzaan A, Hanemaayer K, Muhamad M, de Waal MWM, Achterberg WP. Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards. Brain Sci 2021; 11:brainsci11070869. [PMID: 34210018 PMCID: PMC8301856 DOI: 10.3390/brainsci11070869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/16/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022] Open
Abstract
Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.
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Affiliation(s)
- Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Correspondence:
| | - Andrew Westzaan
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Aafje Thuiszorg, Huizen en Zorghotels, Pietersdijk 60, 3079 TD Rotterdam, The Netherlands
| | - Kimberley Hanemaayer
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Franciscus Vlietland Hospital, Vlietlandplein 2, 3118 JH Schiedam, The Netherlands
| | - Muhamad Muhamad
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Stichting Voor Regionale Zorgverlening (Nursing Home), Prins Clauslaan 1, 4691 ZA Tholen, The Netherlands
| | - Margot W. M. de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
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Miranda R, Smets T, Van Den Noortgate N, van der Steen JT, Deliens L, Payne S, Szczerbińska K, Pautex S, Van Humbeeck L, Gambassi G, Kylänen M, Van den Block L. No difference in effects of 'PACE steps to success' palliative care program for nursing home residents with and without dementia: a pre-planned subgroup analysis of the seven-country PACE trial. BMC Palliat Care 2021; 20:39. [PMID: 33678179 PMCID: PMC7937240 DOI: 10.1186/s12904-021-00734-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background ‘PACE Steps to Success’ is a multicomponent training program aiming to integrate generalist and non-disease-specific palliative care in nursing homes. This program did not improve residents’ comfort in the last week of life, but it appeared to improve quality of care and dying in their last month of life. Because this program included only three dementia-specific elements, its effects might differ depending on the presence or stage of dementia. We aimed to investigate whether the program effects differ between residents with advanced, non-advanced, and no dementia. Methods Pre-planned subgroup analysis of the PACE cluster-randomized controlled trial in 78 nursing homes in seven European countries. Participants included residents who died in the previous 4 months. The nursing home staff or general practitioner assessed the presence of dementia; severity was determined using two highly-discriminatory staff-reported instruments. Using after-death questionnaires, staff assessed comfort in the last week of life (Comfort Assessment in Dying–End-of-Life in Dementia-scale; primary outcome) and quality of care and dying in the last month of life (Quality of Dying in Long-Term Care scale; secondary outcome). Results At baseline, we included 177 residents with advanced dementia, 126 with non-advanced dementia and 156 without dementia. Post-intervention, respectively in the control and the intervention group, we included 136 and 104 residents with advanced dementia, 167 and 110 with non-advanced dementia and 157 and 137 without dementia. We found no subgroup differences on comfort in the last week of life, comparing advanced versus without dementia (baseline-adjusted mean sub-group difference 2.1; p-value = 0.177), non-advanced versus without dementia (2.7; p = 0.092), and advanced versus non-advanced dementia (− 0.6; p = 0.698); or on quality of care and dying in the last month of life, comparing advanced and without dementia (− 0.6; p = 0.741), non-advanced and without dementia (− 1.5; p = 0.428), and advanced and non-advanced dementia (0.9; p = 0.632). Conclusions The lack of subgroup difference suggests that while the program did not improve comfort in dying residents with or without dementia, it appeared to equally improve quality of care and dying in the last month of life for residents with dementia (regardless of the stage) and those without dementia. A generalist and non-disease-specific palliative care program, such as PACE Steps to Success, is a useful starting point for future palliative care improvement in nursing homes, but to effectively improve residents’ comfort, this program needs further development. Trial registration ISRCTN, ISRCTN14741671. Registered 8 July 2015 – Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00734-1.
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Affiliation(s)
- Rose Miranda
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.
| | - Tinne Smets
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
| | | | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC-VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sophie Pautex
- Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
| | | | - Giovanni Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Lieve Van den Block
- Vrije Universiteit Brussel & Ghent University, End-of-Life Care Research Group, Laarbeeklaan 103, 1090, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
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12
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Dupont C, De Schreye R, Cohen J, De Ridder M, Van den Block L, Deliens L, Leemans K. Pilot Study to Develop and Test Palliative Care Quality Indicators for Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:829. [PMID: 33478066 PMCID: PMC7835963 DOI: 10.3390/ijerph18020829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 11/17/2022]
Abstract
An increasingly frail population in nursing homes accentuates the need for high quality care at the end of life and better access to palliative care in this context. Implementation of palliative care and its outcomes can be monitored by using quality indicators. Therefore, we developed a quality indicator set for palliative care in nursing homes and a tailored measurement procedure while using a mixed-methods design. We developed the instrument in three phases: (1) literature search, (2) interviews with experts, and (3) indicator and measurement selection by expert consensus (RAND/UCLA). Second, we pilot tested and evaluated the instrument in nine nursing homes in Flanders, Belgium. After identifying 26 indicators in the literature and expert interviews, 19 of them were selected through expert consensus. Setting-specific themes were advance care planning, autonomy, and communication with family. The quantitative and qualitative analyses showed that the indicators were measurable, had good preliminary face validity and discriminative power, and were considered to be useful in terms of quality monitoring according to the caregivers. The quality indicators can be used in a large implementation study and process evaluation in order to achieve continuous monitoring of the access to palliative care for all of the residents in nursing homes.
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Affiliation(s)
- Charlèss Dupont
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium
| | - Robrecht De Schreye
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
| | - Joachim Cohen
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, University Hospital Brussels, 1090 Brussel, Belgium;
| | - Lieve Van den Block
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium
| | - Luc Deliens
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium
- Department of Public Health and Primary Care, Ghent University, 9000 Ghent, Belgium
| | - Kathleen Leemans
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), 1090 Brussel, Belgium; (R.D.S.); (J.C.); (L.V.d.B.); (L.D.)
- Department of Radiotherapy, University Hospital Brussels, 1090 Brussel, Belgium;
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13
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Lamppu PJ, Pitkala KH. Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2020; 22:268-278. [PMID: 33121871 DOI: 10.1016/j.jamda.2020.09.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations. DESIGN A systematic review with a narrative summary. SETTING AND PARTICIPANTS Residents in nursing homes and other long-term care facilities. METHODS We searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed. RESULTS The search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial. CONCLUSIONS AND IMPLICATIONS Irrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.
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Affiliation(s)
- Pauli J Lamppu
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Geriatric Clinic, Helsinki Hospital, Helsinki, Finland.
| | - Kaisu H Pitkala
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
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14
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Sulaiman SK, Aldersey HM, DePaul VG, Kaka B. Selection of a quality of life instrument for polio survivors in Northwest Nigeria. Health Qual Life Outcomes 2020; 18:309. [PMID: 32958050 PMCID: PMC7507732 DOI: 10.1186/s12955-020-01552-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 09/01/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To generate high-quality evidence, contextually relevant outcome measurement instruments are required. Quality of life evaluation among polio survivors typically involves the use of generic instruments, which are developed and validated among a different groups of people. There is no clear evidence whether these instruments are appropriate for the measurement of quality of life among polio survivors in northwest Nigeria. The purpose of this review is to identify and select a pre-existing instrument that is best suited for the measurement of quality of life among polio survivors in northwest Nigeria. METHODS Using the findings of a previous scoping review of the literature and qualitative descriptive study, we screened 11 quality of life instruments that are used in polio literature. We identified and selected the most appropriate instrument, which reflected the perspectives of polio survivors in northwest Nigeria and at the same time exhibited good measurement properties. RESULTS The Quality of Life Index, World Health Organization Quality of Life Brief, and Comprehensive Quality of Life Scale are consistent with the perspectives of polio survivors in northwest Nigeria and have satisfactory measurement properties. Among these instruments, the Quality of Life Index satisfied most of the screening criteria we employed and is suitable for cross-cultural adaptation in northwest Nigeria. CONCLUSION Most instruments that are employed to evaluate the quality of life of polio survivors were not primarily designed as a measure of quality of life. To select the appropriate instrument, there is a need to consider and reflect the perspectives of the individuals, to improve the validity of the measurement.
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Affiliation(s)
- Surajo Kamilu Sulaiman
- School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George Street, Kingston, Ontario K7L 3N6 Canada
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, PMB 3011 Nigeria
| | - Heather Michelle Aldersey
- School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George Street, Kingston, Ontario K7L 3N6 Canada
| | - Vincent G. DePaul
- School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George Street, Kingston, Ontario K7L 3N6 Canada
| | - Bashir Kaka
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, PMB 3011 Nigeria
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15
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Miranda R, van der Steen JT, Smets T, Van den Noortgate N, Deliens L, Payne S, Kylänen M, Szczerbińska K, Gambassi G, Van den Block L. Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study. Int J Geriatr Psychiatry 2020; 35:719-727. [PMID: 32128874 DOI: 10.1002/gps.5290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia. METHODS Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments. RESULTS The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort. CONCLUSIONS Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Expertise center for Palliative Care, Amsterdam, The Netherlands.,Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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16
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Perception of the Quality of Communication With Physicians Among Relatives of Dying Residents of Long-term Care Facilities in 6 European Countries: PACE Cross-Sectional Study. J Am Med Dir Assoc 2020; 21:331-337. [DOI: 10.1016/j.jamda.2019.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/24/2019] [Accepted: 05/04/2019] [Indexed: 02/07/2023]
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17
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Abstract
OBJECTIVES To conceptualize a "good end of life" for people with dementia from the perspectives of bereaved family caregivers in Japan. DESIGN AND PARTICIPANTS A qualitative study using in-depth, semi-structured interviews focused on the family caregivers' perceptions of their loved one's experiences. Family caregivers who had lost their relatives with dementia more than six months previously were recruited using maximum variation sampling by cultural subpopulation. A thematic analysis was conducted. RESULTS From 30 interviews held, four main themes emerged. A good end of life for people with dementia means experiencing a "Peaceful Death" while "Maintaining Personhood" at a "Preferred Place" allowing for feelings of "Life Satisfaction." A "Preferred Place" emerged as a basic requirement to achieving a good end of life according to the three other themes, in particular, "Maintaining Personhood." However, the interviewees experienced difficulties in ensuring that their loved ones stayed at a "Preferred Place." CONCLUSIONS Despite different cultural backgrounds, perceptions of a good end of life with dementia were remarkably similar between Japan and Western countries. However, recent societal changes in family structures and long-term care access in Japan may explain the theme of a comfortable place taking a central position. We suggest that these themes be considered and translated into care goals. They could supplement established end-of-life care goals for quality of life in dementia, which aim to maximize functioning and increase comfort. TRIAL REGISTRATION NUMBER Ethics Committee of the Graduate School and Faculty of Medicine, Kyoto University (R0808-2).
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18
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Van den Block L, Honinx E, Pivodic L, Miranda R, Onwuteaka-Philipsen BD, van Hout H, Pasman HRW, Oosterveld-Vlug M, Ten Koppel M, Piers R, Van Den Noortgate N, Engels Y, Vernooij-Dassen M, Hockley J, Froggatt K, Payne S, Szczerbinska K, Kylänen M, Gambassi G, Pautex S, Bassal C, De Buysser S, Deliens L, Smets T. Evaluation of a Palliative Care Program for Nursing Homes in 7 Countries: The PACE Cluster-Randomized Clinical Trial. JAMA Intern Med 2020; 180:233-242. [PMID: 31710345 PMCID: PMC6865772 DOI: 10.1001/jamainternmed.2019.5349] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE High-quality evidence on how to improve palliative care in nursing homes is lacking. OBJECTIVE To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio. INTERVENTIONS The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death. MAIN OUTCOMES AND MEASURES The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1). RESULTS Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents' comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, -0.55; 95% CI, -1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018. CONCLUSIONS AND RELEVANCE Residents' comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN14741671.
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Affiliation(s)
- Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Elisabeth Honinx
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Lara Pivodic
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Rose Miranda
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hein van Hout
- Amsterdam Public Health Research Institute, Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - H Roeline W Pasman
- Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mariska Oosterveld-Vlug
- Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Maud Ten Koppel
- Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruth Piers
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Nele Van Den Noortgate
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Jo Hockley
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Katherine Froggatt
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Katarzyna Szczerbinska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Giovanni Gambassi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sophie Pautex
- Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
| | - Catherine Bassal
- Center for the Interdisciplinary Study of Gerontology and Vulnerability (CIGEV), University of Geneva, Geneva, Switzerland
| | - Stefanie De Buysser
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Belgium
| | - Luc Deliens
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Tinne Smets
- VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
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19
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Puente-Fernández D, Palma-Ayllón E, Sánchez-García MR, Hueso-Montoro C, Esteban-Burgos AA, Montoya-Juárez R. Development of a Scale Based on Nursing Outcome Classification "Dignified Life Closure" (1307) to Assess End-of-Life Dignity of Patients in Care Homes for the Elderly. Int J Nurs Knowl 2019; 31:44-49. [PMID: 31743568 DOI: 10.1111/2047-3095.12264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To develop and pilot the DD-14 scale, a 14-indicator scale based on the Nursing Outcome Classification "Dignified life closure" (1307). METHODS Sixteen experts selected 14 indicators for Spanish populations. Six care home nurses piloted the scale in 50 terminal patients without cognitive impairment. Factorial and reliability analyses were performed and correlations were determined with dependency, symptomatology, and palliative care quality. FINDINGS DD-14 demonstrated high reliability (α = 0.916) and a stable factorial structure. It was not influenced by sex, age, or disease and correlated positively with the Barthel index (r = .622; p = .00) and negatively with the Palliative Outcome Scale (r = -.542;p = .00). CONCLUSIONS DD-14 is a useful scale for evaluating end-of-life dignity. IMPLICATIONS FOR NURSING PRACTICE This instrument could be useful in planning nursing interventions.
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Affiliation(s)
- Daniel Puente-Fernández
- Daniel Puente-Fernández, MSc, RN, is a PhD Student at Clinical Medicine and Public Health Doctoral Program, University of Granada, Granada, Spain
| | | | | | - César Hueso-Montoro
- César Hueso-Montoro, PhD, RN, is a Lecturer at Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Ana Alejandra Esteban-Burgos
- Ana Alejandra Esteban-Burgos, MSc, RN, is a PhD Student at Clinical Medicine and Public Health Doctoral Program, University of Granada, Granada, Spain
| | - Rafael Montoya-Juárez
- Rafael Montoya-Juárez, PhD, RN, is Lecturer at Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain
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20
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Tools Measuring Quality of Death, Dying, and Care, Completed after Death: Systematic Review of Psychometric Properties. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:183-197. [PMID: 30141020 PMCID: PMC6397142 DOI: 10.1007/s40271-018-0328-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Introduction Measuring the quality of care at the end of life and/or the quality of dying and death can be challenging. Some measurement tools seek to assess the quality of care immediately prior to death; others retrospectively assess, following death, the quality of end-of-life care. The comparative evaluation of the properties and application of the various instruments has been limited. Objective This systematic review identified and critically appraised the psychometric properties and applicability of tools used after death. Method We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by systematically searching MEDLINE, Embase, CINAHL, and PsycINFO for relevant studies. We then appraised the psychometric properties and the quality of reporting of the psychometric properties of the identified tools using the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist. The protocol of this systematic review has been registered on PROSPERO (CRD42016047296). Results The search identified 4751 studies. Of these, 33 met the inclusion criteria, reporting on the psychometric properties of 67 tools. These tools measured quality of care at the end of life (n = 35), quality of dying and death (n = 22), or both quality of care at the end of life and dying and death (n = 10). Most tools were completed by family carers (n = 57), with some also completed by healthcare professionals (HCPs) (n = 2) or just HCPs (n = 8). No single tool was found to be adequate across all the psychometric properties assessed. Two quality of care at the end of life tools—Care of the Dying Evaluation and Satisfaction with Care at the End of Life in Dementia—had strong psychometric properties in most respects. Two tools assessing quality of dying and death—the Quality of Dying and Death and the newly developed Staff Perception of End of Life Experience—had limited to moderate evidence of good psychometric properties. Two tools assessing both quality of care and quality of dying and death—the Quality Of Dying in Long-Term Care for cognitively intact populations and Good Death Inventory (Korean version)—had the best psychometric properties. Conclusion Four tools demonstrated some promise, but no single tool was consistent across all psychometric properties assessed. All tools identified would benefit from further psychometric testing. Electronic supplementary material The online version of this article (10.1007/s40271-018-0328-2) contains supplementary material, which is available to authorized users.
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21
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Boyd M, Frey R, Balmer D, Robinson J, McLeod H, Foster S, Slark J, Gott M. End of life care for long-term care residents with dementia, chronic illness and cancer: prospective staff survey. BMC Geriatr 2019; 19:137. [PMID: 31117991 PMCID: PMC6532195 DOI: 10.1186/s12877-019-1159-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. Methods After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident’s death. Results Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. Conclusions Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.
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Affiliation(s)
- Michal Boyd
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand. .,Freemasons' Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand.
| | - Rosemary Frey
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Deborah Balmer
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Jackie Robinson
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Heather McLeod
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Susan Foster
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Julia Slark
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Merryn Gott
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
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22
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Frey R, Balmer D, Robinson J, Gott M, Boyd M. The Effect of Residential Aged Care Size, Ownership Model, and Multichain Affiliation on Resident Comfort and Symptom Management at the End of Life. J Pain Symptom Manage 2019; 57:545-555.e1. [PMID: 30508638 DOI: 10.1016/j.jpainsymman.2018.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 01/30/2023]
Abstract
CONTEXT In most resource-rich countries, a large and growing proportion of older adults with complex needs will die while in a residential aged care (RAC) facility. OBJECTIVES This study describes the impact of facility size (small/large), ownership model (profit/nonprofit) and provider (independent/chain) on resident comfort, and symptom management as reported by RAC staff. METHODS This retrospective "after-death" study collected decedent resident data from a subsample of 51 hospital-level RAC facilities in New Zealand. Symptom Management at the End-of-Life in Dementia and Comfort Assessment in Dying at End of life with Dementia (SM-EOLD and CAD-EOLD, respectively) scales were used by RAC staff who were closely associated with 217 deceased residents. Data collection occurred from January 2016 to February 2017. RESULTS Results indicated that residents of large, nonprofit facilities experienced greater comfort at the end of life (CAD-EOLD) as indicated by a higher mean score of 37.21 (SD = 4.85, 95% CI = 34.4, 40.0) than residents of small for-profit facilities who recorded a lower mean score of 31.56 (SD = 6.20, 95% CI = 29.6, 33.4). There was also evidence of better symptom management for residents of chain facilities, with a higher mean score for symptom management (SM-EOLD total score) recorded for residents of chain facilities (mean = 28.07, SD = 7.64, 95% CI = 26.47, 29.66) than the mean score for independent facilities (mean = 23.93, SD = 8.72, 95% CI = 21.65, 26.20). CONCLUSION Findings suggest that there are differences in the quality of end-of-life care given in RAC based on size, ownership model, and chain affiliation.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, Auckland, New Zealand
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23
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Bolt SR, Verbeek L, Meijers JMM, van der Steen JT. Families' Experiences With End-of-Life Care in Nursing Homes and Associations With Dying Peacefully With Dementia. J Am Med Dir Assoc 2019; 20:268-272. [PMID: 30718151 DOI: 10.1016/j.jamda.2018.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/28/2018] [Accepted: 12/08/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To examine family caregivers' experiences with end-of-life care for nursing home residents with dementia and associations with the residents dying peacefully. DESIGN A secondary data analysis of family caregiver data collected in the observational Dutch End of Life in Dementia (DEOLD) study between 2007 and 2010. SETTING AND PARTICIPANTS Data were collected at 34 Dutch nursing homes (2799 beds) representing the nation. We included 252 reports from bereaved family members of nursing home residents with dementia. MEASURES The primary outcome was dying peacefully, assessed by family members using an item from the Quality of Dying in Long-term Care instrument. Unpleasant experiences with end-of-life care were investigated using open-ended questions. Overall satisfaction with end-of-life care was assessed with the End-of-Life Satisfaction With Care (EOLD-SWC) scale, and families' appraisal of decision making was measured with the Decision Satisfaction Inventory. Associations were investigated with multilevel linear regression analyses using generalized estimating equations. RESULTS Families' reports of unpleasant experiences translated into 2 themes: neglect and lack of respect. Neglect involved facing inaccessibility, disinterest, or discontinuity of relations, and negligence in tailored care and information. Lack of respect involved perceptions of being purposefully disregarded, an insensitive approach towards resident and family, noncompliance with agreements, and violations of privacy. Unpleasant experiences with end-of-life care were negatively associated with families' perceptions of the resident dying peacefully. Families' assessment of their relative dying peacefully was positively associated with satisfaction with end-of-life care and decision making. CONCLUSIONS/IMPLICATIONS Families' reports of unpleasant experiences with end-of-life care may inform practice to improve perceived quality of dying of their loved ones. Humane and compassionate care and attention from physicians and other staff for resident and family may facilitate recollections of a peaceful death.
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Affiliation(s)
- Sascha R Bolt
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands.
| | - Laura Verbeek
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Judith M M Meijers
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands; Zuyderland Care, Zuyderland Medical Center, Sittart-Geleen, the Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
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24
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Pivodic L, Smets T, Van den Noortgate N, Onwuteaka-Philipsen BD, Engels Y, Szczerbińska K, Finne-Soveri H, Froggatt K, Gambassi G, Deliens L, Van den Block L. Quality of dying and quality of end-of-life care of nursing home residents in six countries: An epidemiological study. Palliat Med 2018; 32:1584-1595. [PMID: 30273519 PMCID: PMC6238165 DOI: 10.1177/0269216318800610] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nursing homes are among the most common places of death in many countries. AIM To determine the quality of dying and end-of-life care of nursing home residents in six European countries. DESIGN Epidemiological survey in a proportionally stratified random sample of nursing homes. We identified all deaths of residents of the preceding 3-month period. Main outcomes: quality of dying in the last week of life (measured using End-of-Life in Dementia Scales - Comfort Assessment while Dying (EOLD-CAD)); quality of end-of-life care in the last month of life (measured using Quality of Dying in Long-Term Care (QoD-LTC) scale). Higher scores indicate better quality. SETTING/PARTICIPANTS Three hundred and twenty-two nursing homes in Belgium, Finland, Italy, the Netherlands, Poland and England. Participants were staff (nurses or care assistants) most involved in each resident's care. RESULTS Staff returned questionnaires regarding 1384 (81.6%) of 1696 deceased residents. The End-of-Life in Dementia Scales - Comfort Assessment while Dying mean score (95% confidence interval) (theoretical 14-42) ranged from 29.9 (27.6; 32.2) in Italy to 33.9 (31.5; 36.3) in England. The Quality of Dying in Long-Term Care mean score (95% confidence interval) (theoretical 11-55) ranged from 35.0 (31.8; 38.3) in Italy to 44.1 (40.7; 47.4) in England. A higher End-of-Life in Dementia Scales - Comfort Assessment while Dying score was associated with country ( p = 0.027), older age ( p = 0.012), length of stay ⩾1 year ( p = 0.034), higher functional status ( p < 0.001). A higher Quality of Dying in Long-Term Care score was associated with country ( p < 0.001), older age ( p < 0.001), length of stay ⩾1 year ( p < 0.001), higher functional status ( p = 0.002), absence of dementia ( p = 0.001), death in nursing home ( p = 0.033). CONCLUSION The quality of dying and quality of end-of-life care in nursing homes in the countries studied are not optimal. This includes countries with high levels of palliative care development in nursing homes such as Belgium, the Netherlands and England.
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Affiliation(s)
- Lara Pivodic
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels and Ghent, Belgium
| | - Tinne Smets
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels and Ghent, Belgium
| | | | - Bregje D Onwuteaka-Philipsen
- 3 EMGO+ Institute for Health and Care Research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Yvonne Engels
- 4 Radboud University Medical Center, Department of Anesthesiology, Pain and Palliative Medicine, Nijmegen, The Netherlands
| | - Katarzyna Szczerbińska
- 5 Unit for Research on Aging Society, Department of Sociology, Chair of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Cracow, Poland
| | | | - Katherine Froggatt
- 7 International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Giovanni Gambassi
- 8 Università Cattolica del Sacro Cuore, Rome, Italy.,9 Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels and Ghent, Belgium
| | - Lieve Van den Block
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels and Ghent, Belgium
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25
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Froggatt K, Patel S, Perez Algorta G, Bunn F, Burnside G, Coast J, Dunleavy L, Goodman C, Hardwick B, Kinley J, Preston NJ, Walshe C. Namaste Care in nursing care homes for people with advanced dementia: protocol for a feasibility randomised controlled trial. BMJ Open 2018; 8:e026531. [PMID: 30478131 PMCID: PMC6254402 DOI: 10.1136/bmjopen-2018-026531] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Many people living with advanced dementia live and die in nursing care homes. The quality of life, care and dying experienced by these people is variable. Namaste Care is a multisensory programme of care developed for people with advanced dementia. While there is emerging evidence that Namaste Care may be beneficial for people with dementia, there is a need to conduct a feasibility study to establish the optimum way of delivering this complex intervention and whether benefits can be demonstrated in end-of-life care, for individuals and service delivery. The aim of the study is to ascertain the feasibility of conducting a full trial of the Namaste Care intervention. METHODS AND ANALYSIS A feasibility study, comprising a parallel, two-arm, multicentre cluster controlled randomised trial with embedded process and economic evaluation. Nursing care homes (total of eight) who deliver care to those with advanced dementia will be randomly allocated to intervention (delivered at nursing care home level) or control. Three participant groups will be recruited: residents with advanced dementia, informal carers of a participating resident and nursing care home staff. Data will be collected for 6 months. Feasibility objectives concern the recruitment and sampling of nursing homes, residents, informal carers and staff; the selection and timing of primary (quality of dying and quality of life) and secondary clinical outcome measures (person centredness, symptom presence, agitation, quality of life, resource use and costs and residents' activity monitored using actigraphy). Acceptability, fidelity and sustainability of the intervention will be assessed using semistructured interviews with staff and informal carers. ETHICS AND DISSEMINATION This protocol has been approved by NHS Wales Research Ethics Committee 5 (ref: 17/WA0378). Dissemination plans include working with a public involvement panel, through a website (http://www.namastetrial.org.uk), social media, academic and practice conferences and via peer reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN14948133; Pre-results.
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Affiliation(s)
- Katherine Froggatt
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Shakil Patel
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | | | - Frances Bunn
- Department of Health and Human Sciences, University of Herfordshire, Hatfield, UK
| | - Girvan Burnside
- Clinical Trials Research Centre, The University of Liverpool, Liverpool, UK
| | | | - Lesley Dunleavy
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Claire Goodman
- Department of Health and Human Sciences, University of Herfordshire, Hatfield, UK
| | - Ben Hardwick
- Clinical Trials Research Centre, The University of Liverpool, Liverpool, UK
| | | | - Nancy J Preston
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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26
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Smaling HJA, Joling KJ, van de Ven PM, Bosmans JE, Simard J, Volicer L, Achterberg WP, Francke AL, van der Steen JT. Effects of the Namaste Care Family programme on quality of life of nursing home residents with advanced dementia and on family caregiving experiences: study protocol of a cluster-randomised controlled trial. BMJ Open 2018; 8:e025411. [PMID: 30327407 PMCID: PMC6196971 DOI: 10.1136/bmjopen-2018-025411] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Quality of life of people with advanced dementia living in nursing homes is often suboptimal. Family caregivers can feel frustrated with limited contact with their relatives, which results in visits that are perceived as stressful and not very meaningful. Few psychosocial interventions are specifically developed for people with advanced dementia, and actively involve family caregivers or volunteers. Also, interventions usually stop when it becomes difficult for people to participate. The Namaste Care Family programme aims to increase the quality of life of people with advanced dementia, and improve family caregiving experiences through connecting to people and making them comfortable. METHODS AND ANALYSIS Our study will evaluate the effects of the Namaste Care Family programme on quality of life of people with advanced dementia living in nursing homes and family caregiving experiences using a cluster-randomised controlled trial. Longitudinal analyses will be performed taking into account clustering at the nursing home level. Both a cost-effectiveness and a cost-utility analysis from a societal perspective will be performed. We will modify the Namaste Care Family programme to increase family and volunteer involvement in ongoing and end-of-life care. Data collection involves assessments by family caregivers, nursing staff and elderly care physicians using questionnaires, and observations by the researchers at baseline and multiple times over 12 months. The last questionnaire will be sent up to month 24 after the death of the person with dementia. During semistructured interviews, the feasibility, accessibility and sustainability of the Namaste Care Family programme will be assessed. ETHICS AND DISSEMINATION The study protocol is approved by the Medical Ethics Review Committee of the VU University Medical Center in Amsterdam (protocol no. 2016.399) and registered with the Nederlands Trial Register (NTR5692). The findings will be disseminated via publications in peer-reviewed journals, conference presentations and presentations for healthcare professionals where appropriate. TRIAL REGISTRATION NUMBER NTR5692.
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Affiliation(s)
- Hanneke J A Smaling
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Karlijn J Joling
- Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Amsterdam Public Health Research Institute, VU University, Amsterdam, The Netherlands
| | - Joyce Simard
- School of Nursing and Midwifery, College of Health and Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Ladislav Volicer
- School of Aging Studies, University of South Florida, Land O'Lakes, Florida, USA
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health, VU University Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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27
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Iaboni A, Van Ooteghem K, Marcil MN, Cockburn A, Flint AJ, Grossman D, Keren R. A Palliative Approach to Falls in Advanced Dementia. Am J Geriatr Psychiatry 2018; 26:407-415. [PMID: 29336907 DOI: 10.1016/j.jagp.2017.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/10/2017] [Accepted: 11/30/2017] [Indexed: 11/26/2022]
Abstract
Falls are viewed as a preventable cause of injury, functional loss, and death in older adults with dementia, and have been used as a marker of quality of care in long-term care facilities. Despite intensive intervention around fall prevention in these settings, falls and injury remain frequent, particularly among residents in the advanced stages of dementia. In this clinical review, we consider the common challenges and pitfalls in both the management of falls and the provision of palliative care in advanced dementia. We then describe a palliative approach to falls in advanced dementia that involves identifying individuals who would benefit from this care approach, framing falls and loss of mobility as a quality of life issue, and devising an individualized symptom assessment and management plan. A palliative approach can lead to recognition and acceptance that recurrent falls are often symptomatic of advanced dementia, and that not all falls are preventable. We conclude that falls in the advanced stage of dementia can be sentinel events indicating the need for a palliative approach to care. Rather than replace falls prevention activities, a palliative approach to falls prompts us to select dementia stage-appropriate interventions with a focus on symptom management, comfort, and dignity.
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Affiliation(s)
- Andrea Iaboni
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Centre for Mental Health, University Health Network, Toronto, ON, Canada; Departments of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Karen Van Ooteghem
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Meghan N Marcil
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Amy Cockburn
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Alastair J Flint
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Departments of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Daphna Grossman
- Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Freeman Centre for the Advancement of Palliative Care, North York General Hospital, Toronto, ON, Canada
| | - Ron Keren
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Centre for Mental Health, University Health Network, Toronto, ON, Canada; Departments of Psychiatry, University of Toronto, Toronto, ON, Canada
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Smets T, Onwuteaka-Philipsen BBD, Miranda R, Pivodic L, Tanghe M, van Hout H, Pasman RHRW, Oosterveld-Vlug M, Piers R, Van Den Noortgate N, Wichmann AB, Engels Y, Vernooij-Dassen M, Hockley J, Froggatt K, Payne S, Szczerbińska K, Kylänen M, Leppäaho S, Barańska I, Gambassi G, Pautex S, Bassal C, Deliens L, Van den Block L. Integrating palliative care in long-term care facilities across Europe (PACE): protocol of a cluster randomized controlled trial of the 'PACE Steps to Success' intervention in seven countries. BMC Palliat Care 2018. [PMID: 29530091 PMCID: PMC5848517 DOI: 10.1186/s12904-018-0297-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the ‘PACE Steps to Success’ palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries. Methods We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the ‘Pace Steps to Success intervention’ or to ‘care as usual’. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey). Secondary outcomes: resident’s quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework. Discussion The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities ‘PACE Steps to Success’ in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems. Trial registration The study is registered at www.isrctn.com – ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015.
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Affiliation(s)
- Tinne Smets
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
| | - Bregje B D Onwuteaka-Philipsen
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Rose Miranda
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lara Pivodic
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Marc Tanghe
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Hein van Hout
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Roeline H R W Pasman
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Mariska Oosterveld-Vlug
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Anne B Wichmann
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yvonne Engels
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Jo Hockley
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katherine Froggatt
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Suvi Leppäaho
- National Institute for Health and Welfare, Helsinki, Finland
| | - Ilona Barańska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Faculty of Health Sciences, Jagiellonian University Medical College, ul. Michałowskiego 12, 31-126, Kraków, Poland
| | | | - Sophie Pautex
- Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
| | - Catherine Bassal
- Center for the Interdisciplinary Study of Gerontology and Vulnerability (CIGEV), University of Geneva, Geneva, Switzerland
| | - Luc Deliens
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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Verreault R, Arcand M, Misson L, Durand PJ, Kroger E, Aubin M, Savoie M, Hadjistavropoulos T, Kaasalainen S, Bédard A, Grégoire A, Carmichael PH. Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions. Palliat Med 2018; 32:613-621. [PMID: 28731379 DOI: 10.1177/0269216317719588] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care. AIM To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities. DESIGN Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying. PARTICIPANTS A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group). RESULTS The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group. CONCLUSIONS Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.
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Affiliation(s)
- René Verreault
- 1 Faculty of Medicine, Laval University, Quebec City, QC, Canada.,2 Quebec Centre of Excellence on Aging, Quebec City, QC, Canada
| | - Marcel Arcand
- 3 Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Lucie Misson
- 2 Quebec Centre of Excellence on Aging, Quebec City, QC, Canada
| | - Pierre J Durand
- 1 Faculty of Medicine, Laval University, Quebec City, QC, Canada.,2 Quebec Centre of Excellence on Aging, Quebec City, QC, Canada
| | | | - Michèle Aubin
- 1 Faculty of Medicine, Laval University, Quebec City, QC, Canada.,2 Quebec Centre of Excellence on Aging, Quebec City, QC, Canada
| | | | | | | | - Annick Bédard
- 2 Quebec Centre of Excellence on Aging, Quebec City, QC, Canada
| | - Annie Grégoire
- 3 Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
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30
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Boogaard JA, de Vet HCW, van Soest-Poortvliet MC, Anema JR, Achterberg WP, van der Steen JT. Effects of two feedback interventions on end-of-life outcomes in nursing home residents with dementia: A cluster-randomized controlled three-armed trial. Palliat Med 2018; 32:693-702. [PMID: 29343173 PMCID: PMC5851130 DOI: 10.1177/0269216317750071] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite increased attention for palliative care in dementia, recent studies found burdensome symptoms and unmet family caregiver needs in the last phase of life. Feedback is being used to improve the quality of palliative care, but we do not know how effective it is. AIM To assess the effect of two feedback strategies on perceived quality of end-of-life care and comfort in dying nursing home residents with dementia. METHODS In a cluster-randomized controlled trial, the End-of-Life in Dementia-Satisfaction With Care and the End-of-Life in Dementia-Comfort Assessment in Dying scales were completed by bereaved family caregivers of residents with dementia of 18 Dutch nursing homes. Two feedback strategies, generic feedback with mean End-of-Life in Dementia-scores and feedback with individual (patient-specific) End-of-Life in Dementia-scores, were compared to no feedback provided. The intervention groups discussed End-of-Life in Dementia-ratings in team meetings and formulated actions to improve care. Multi-level analyses assessed effects. RESULTS A total of 668 families rated the End-of-Life in Dementia-instruments. Compared to no feedback, the generic strategy resulted in lower quality of end-of-life care in unadjusted ( B = -1.65, confidence interval = -3.27; -0.21) and adjusted analyses ( B = -2.41, confidence interval = -4.07; -0.76), while there was no effect on comfort. The patient-specific strategy did not affect the quality of end-of-life care, but it increased comfort in unadjusted analyses (only, B = 2.20, confidence interval = 0.15; 4.39; adjusted: B = 1.88, confidence interval = -0.34; 4.10). CONCLUSION Neither feedback strategy improved end-of-life outcome. Perhaps, skills to translate the feedback into care improvement actions were insufficient. Feedback with favorable family ratings might even have triggered opposite effects. Trial number: NTR3942.
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Affiliation(s)
- Jannie A Boogaard
- 1 Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Henrica C W de Vet
- 2 Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Johannes R Anema
- 4 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Wilco P Achterberg
- 5 Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jenny T van der Steen
- 5 Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,6 Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
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31
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Zimmerman S, van der Steen JT. It's Not a Small World After All. J Am Med Dir Assoc 2018; 19:187-189. [PMID: 29477772 DOI: 10.1016/j.jamda.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/08/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jenny T van der Steen
- Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands; Radboud University Medical Center, Department of Primary and Community Care, Nijmegen, The Netherlands
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32
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Boogaard JA, Werner P, Zisberg A, van der Steen JT. Examining trust in health professionals among family caregivers of nursing home residents with advanced dementia. Geriatr Gerontol Int 2017; 17:2466-2471. [DOI: 10.1111/ggi.13107] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/23/2017] [Accepted: 04/26/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Jannie A. Boogaard
- Department of General Practice and Elderly Care Medicine; VU University Medical Center; Amsterdam the Netherlands
| | - Perla Werner
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences; University of Haifa; Haifa Israel
| | - Anna Zisberg
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences; University of Haifa; Haifa Israel
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care; Leiden University Medical Center; Leiden the Netherlands
- Department of Primary and Community Care; Radboud university medical center; Nijmegen the Netherlands
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Abstract
OBJECTIVE Our aim was to describe physicians' perceptions of the suffering of their patients who are dying with dementia, many of whom are incompetent with regard to decision making and have difficulty with communicating about the source of their distress and with identifying related factors. METHOD We analyzed data from the nationally representative observational Dutch End-of-Life in Dementia (DEOLD) cohort study (2007-2011), which involved 34 long-term care facilities. A total of 103 physicians completed questionnaires about 330 patients with dementia who had died in a participating facility. Suffering during the last six hours of life was defined as "a patient being disturbed by or aware of symptoms," "suffering until the end or death was a struggle"-all related to objective indicators of lack of comfort. We employed generalized estimating equation models to assess associations of suffering with the characteristics of physicians and patients, the patient's death, and the decision-making process. RESULTS In 13.8% of cases, the physician felt that the patient had suffered. An unexpected death and death with pneumonia were strongly (an odds ratios close to 6) associated with suffering, and suffering was also independently associated with the physician's perception of worse quality of end-of-life care, death with cardiovascular disease, a less experienced physician, no palliative sedation, and a younger patient. SIGNIFICANCE OF RESULTS Most patients with dementia did not suffer during their final hours of life, according to their physicians. There are a number of factors associated with suffering, among them death with pneumonia and unexpected death. We may not be able to have much influence on death from pneumonia, but quality of care and an unexpected death are reasonable targets for intervention. Earlier identification of the beginning of the dying process would allow time to better prepare for approaching death, which would provide a source of comfort.
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Carlozzi NE, Downing NR, McCormack MK, Schilling SG, Perlmutter JS, Hahn EA, Lai JS, Frank S, Quaid KA, Paulsen JS, Cella D, Goodnight SM, Miner JA, Nance MA. New measures to capture end of life concerns in Huntington disease: Meaning and Purpose and Concern with Death and Dying from HDQLIFE (a patient-reported outcomes measurement system). Qual Life Res 2016; 25:2403-2415. [PMID: 27393121 DOI: 10.1007/s11136-016-1354-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Huntington disease (HD) is an incurable terminal disease. Thus, end of life (EOL) concerns are common in these individuals. A quantitative measure of EOL concerns in HD would enable a better understanding of how these concerns impact health-related quality of life. Therefore, we developed new measures of EOL for use in HD. METHODS An EOL item pool of 45 items was field tested in 507 individuals with prodromal or manifest HD. Exploratory and confirmatory factor analyses (EFA and CFA, respectively) were conducted to establish unidimensional item pools. Item response theory (IRT) and differential item functioning analyses were applied to the identified unidimensional item pools to select the final items. RESULTS EFA and CFA supported two separate unidimensional sets of items: Concern with Death and Dying (16 items), and Meaning and Purpose (14 items). IRT and DIF supported the retention of 12 Concern with Death and Dying items and 4 Meaning and Purpose items. IRT data supported the development of both a computer adaptive test (CAT) and a 6-item, static short form for Concern with Death and Dying. CONCLUSION The HDQLIFE Concern with Death and Dying CAT and corresponding 6-item short form, and the 4-item calibrated HDQLIFE Meaning and Purpose scale demonstrate excellent psychometric properties. These new measures have the potential to provide clinically meaningful information about end-of-life preferences and concerns to clinicians and researchers working with individuals with HD. In addition, these measures may also be relevant and useful for other terminal conditions.
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Affiliation(s)
- N E Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.
| | - N R Downing
- College of Nursing, The University of Iowa, Iowa City, IA, USA
| | - M K McCormack
- Department of Pathology, Rowan University, Piscataway, NJ, USA
| | - S G Schilling
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - J S Perlmutter
- Departments of Neurology, Radiology, and Anatomy and Neurobiology, Washington University School of Medicine, St. Louis, MO, USA
- Program in Occupational Therapy and Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - E A Hahn
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - J S Lai
- Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Northwestern University, Evanston, IL, USA
- Institute for Health Services Research and Policy Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - S Frank
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K A Quaid
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | - J S Paulsen
- Department of Psychiatry, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
- Department of Neurology, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
- Department of Psychology, The University of Iowa, Iowa City, IA, USA
| | - D Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
- Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Northwestern University, Evanston, IL, USA
- Institute for Health Services Research and Policy Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - S M Goodnight
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - J A Miner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - M A Nance
- Hennepin County Medical Center, Minneapolis, MN, USA
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Comparing Palliative Care in Care Homes Across Europe (PACE): Protocol of a Cross-sectional Study of Deceased Residents in 6 EU Countries. J Am Med Dir Assoc 2016; 17:566.e1-7. [DOI: 10.1016/j.jamda.2016.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022]
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Husebo BS, Achterberg W, Flo E. Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review. CNS Drugs 2016; 30:481-97. [PMID: 27240869 PMCID: PMC4920848 DOI: 10.1007/s40263-016-0342-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life. METHODS A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries. RESULTS Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia? CONCLUSION Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.
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Affiliation(s)
- Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
- Section for Nursing Home Medicine, Municipality of Bergen, Bergen, Norway.
| | - Wilco Achterberg
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
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van der Steen JT, Sampson EL, Van den Block L, Lord K, Vankova H, Pautex S, Vandervoort A, Radbruch L, Shvartzman P, Sacchi V, de Vet HCW, Van Den Noortgate NJA. Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis. J Pain Symptom Manage 2015. [PMID: 26212095 DOI: 10.1016/j.jpainsymman.2015.05.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CONTEXT There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ. OBJECTIVES To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life. METHODS Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools. RESULTS We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations. CONCLUSION This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.
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Affiliation(s)
- Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom; Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Kathryn Lord
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Hana Vankova
- Faculty of Humanities and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Sophie Pautex
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany; Center for Palliative Care, Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg, Bonn, Germany
| | - Pesach Shvartzman
- Pain and Palliative Medicine Unit, Division of Community Health, Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Valentina Sacchi
- Lincolnshire Partnership Foundation Trust, Lincoln, Lincolnshire, United Kingdom
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
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van der Maaden T, van der Steen JT, de Vet HCW, Hertogh CMPM, Koopmans RTCM. Prospective Observations of Discomfort, Pain, and Dyspnea in Nursing Home Residents With Dementia and Pneumonia. J Am Med Dir Assoc 2015; 17:128-35. [PMID: 26410108 DOI: 10.1016/j.jamda.2015.08.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/14/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe observations of suffering in patients with dementia from the diagnosis of pneumonia until cure or death. DESIGN Prospective observational study between January 2012 and May 2014. SETTING Dutch nursing homes (32). PARTICIPANTS Nursing home patients with dementia and pneumonia (n = 193). MEASUREMENTS Independent observers performed observations of patients with dementia scheduled 13 times within the 15 days following diagnosis of pneumonia; twice daily in the first 2 days- to observe discomfort (Discomfort Scale-Dementia of Alzheimer Type; range 0-27), comfort (End Of Life in Dementia-Comfort Assessment in Dying; range 14-42), pain (Pain Assessment in Advanced Dementia; range 0-10), and dyspnea (Respiratory Distress Observation Scale; range 0-16). RESULTS Observational data were obtained for 208 cases of pneumonia in 193 patients. In 71.2% of cases, patients received 1 or more treatments to relieve symptoms such as antipyretics, opioids, or oxygen; 89.4% received antibiotics. Discomfort was highest 1 day after diagnosis [mean Discomfort Scale-Dementia of Alzheimer Type score 8.1 (standard deviation, SD 5.8)], then declined, and stabilized around day 10 [mean 4.5 (SD 4.1)], or increased in the days preceding death. Observed pain and dyspnea followed a comparable pattern. Discomfort patterns did not differ much between cases treated with and without antibiotics. CONCLUSIONS Pneumonia in patients with dementia involved elevated levels of suffering during 10 days following diagnosis and in the days preceding death. Overall observed discomfort was low compared with prior Dutch studies, and the number of treatments to relieve symptoms was higher. Future studies should examine whether symptoms of pneumonia can be relieved even more, and what treatments are the most effective.
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Affiliation(s)
- Tessa van der Maaden
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Henrica C W de Vet
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands; Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands; Radboud Alzheimer Center, Nijmegen, The Netherlands
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De Roo ML, Albers G, Deliens L, de Vet HCW, Francke AL, Van Den Noortgate N, Van den Block L. Physical and Psychological Distress Are Related to Dying Peacefully in Residents With Dementia in Long-Term Care Facilities. J Pain Symptom Manage 2015; 50:1-8. [PMID: 25847852 DOI: 10.1016/j.jpainsymman.2015.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 01/27/2015] [Accepted: 02/02/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT Although dying peacefully is considered an important outcome of high-quality palliative care, large-scale quantitative research on dying peacefully and the factors associated with a peaceful death is lacking. OBJECTIVES To gain insight into how many residents with dementia in long-term care facilities die peacefully, according to their relatives, and whether that assessment is correlated with observed physical and psychological distress. METHODS This was a retrospective cross-sectional study of deceased nursing home residents in a representative sample of long-term care facilities in Flanders, Belgium (2010). Structured post-mortem questionnaires were completed by relatives of the resident, who were asked to what extent they agreed that the resident "appeared to be at peace" during the dying process. Spearman correlation coefficients gave the correlations between physical and psychological distress (as measured using the Symptom Management at the End of Life with Dementia and Comfort Assessment in Dying at the End of Life with Dementia scales) and dying peacefully (as measured using the Quality of Dying in Long Term Care instrument). RESULTS The sample comprised 92 relatives of deceased residents with dementia. In 54% of cases, relatives indicated that the resident died peacefully. Weak-to-moderate correlations (0.2-0.57) were found between dying peacefully and physical distress in the last week of life. Regarding psychological distress, weak-to-moderate correlations were found for both the last week (0.33-0.44) and last month of life (0.28-0.47). CONCLUSION Only half of the residents with dementia died peacefully as perceived by their relatives. Relatives' assessment of whether death was peaceful is related to both physical and psychological distress. Further qualitative research is recommended to gain more in-depth insights into the aspects on which relatives base their judgment of dying peacefully.
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Affiliation(s)
- Maaike L De Roo
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands.
| | - Gwenda Albers
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health & Expertise Center of Palliative Care, EMGO Institute for Health and Care Research, Vrije University Medical Center, Amsterdam, The Netherlands; NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
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van Soest-Poortvliet MC, van der Steen JT, de Vet HCW, Hertogh CMPM, Deliens L, Onwuteaka-Philipsen BD. Comfort goal of care and end-of-life outcomes in dementia: A prospective study. Palliat Med 2015; 29:538-46. [PMID: 25690602 DOI: 10.1177/0269216315570409] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many people with dementia die in a nursing home. A comfort care goal may be beneficial. Little research has examined the relationship between care goals and outcome. AIM To investigate whether family satisfaction with end-of-life care and quality of dying is associated with whether or not dementia patients have a comfort goal shortly after admission. DESIGN AND SETTING Prospective data collection from 28 long-term care facilities (the Dutch End of Life in Dementia study). We included 148 patients who died after prospective follow-up. Main outcomes were family satisfaction (End-of-Life in Dementia-Satisfaction with Care scale; range: 10-40) and quality of dying (End-of-Life in Dementia-Comfort Assessment in Dying; range: 14-42). We performed generalized estimating equations regression analyses to analyze whether these outcomes are associated with a comfort goal established shortly after admission compared with another or no care goal as reported by the physician. RESULTS Families of patients were more satisfied with end-of-life care when a comfort goal was established shortly after admission. We found this pattern only for patients who died within 6 months of admission (adjusted b: 4.5; confidence interval: 2.8, 6.3 vs -1.2; confidence interval: -3.0, 0.6 for longer stay). For quality of dying, no such association was found. CONCLUSION We found that family satisfaction with care is related to a comfort care goal shortly after admission, but quality of dying did not. Establishing a comfort goal at an early stage may be important to the family. Advance care planning interventions should be studied for their effects on patient and family outcome.
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Affiliation(s)
- Mirjam C van Soest-Poortvliet
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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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.
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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
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Retrospective and prospective data collection compared in the Dutch End Of Life in Dementia (DEOLD) study. Alzheimer Dis Assoc Disord 2014; 28:88-94. [PMID: 23632265 DOI: 10.1097/wad.0b013e318293b380] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studying end of life in dementia patients is challenging because of ill-defined prognoses and frequent inability to self-report. We aim to quantify and compare (1) feasibility and (2) sampling issues between prospective and retrospective data collection specific to end-of-life research in long-term care settings. The observational Dutch End of Life in Dementia study (DEOLD; 2007 to 2011) used both prospective data collection (28 facilities; 17 nursing home organizations/physician teams; questionnaires between January 2007 and July 2010, survival until July 2011) and retrospective data collection (exclusively after death; 6 facilities; 2 teams, questionnaires between November 2007 and March 2010). Prospective collection extended from the time of admission to the time after death or conclusion of the study. Prospectively, we recruited 372 families: 218 residents died (59%) and 184 (49%) had complete physician and family after-death assessments. Retrospectively, 119 decedents were enrolled, with 64 (54%) complete assessments. Cumulative data collection over all homes lasted 80 and 8 years, respectively. Per complete after-death assessments in a year, the prospective data collection involved 37.9 beds, whereas this was 7.9 for the retrospective data collection. Although age at death, sex, and survival curves were similar, prospectively, decedents' length of stay was shorter (10.3 vs. 31.4 mo), and fewer residents had advanced dementia (39% vs. 54%). Regarding feasibility, we conclude that prospective data collection is many fold more intensive and complex per complete after-death assessment. Regarding sampling, if not all are followed until death, it results in right censoring and in different, nonrepresentative samples of decedents compared with retrospective data collection. Future work may adjust or stratify for dementia severity and length of stay as key issues to promote comparability between studies.
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Klapwijk MS, Caljouw MAA, van Soest-Poortvliet MC, van der Steen JT, Achterberg WP. Symptoms and treatment when death is expected in dementia patients in long-term care facilities. BMC Geriatr 2014; 14:99. [PMID: 25181947 PMCID: PMC4158395 DOI: 10.1186/1471-2318-14-99] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although dementia at the end of life is increasingly being studied, we lack prospective observational data on dying patients. In this study symptoms were observed in patients with dementia in the last days of life. METHODS When the elderly care physicians in two Dutch nursing homes expected death within one week, symptoms of (dis)comfort, pain and suffering were observed twice daily. For this the Pain Assessment in Advanced Dementia (PAINAD; range 0-10), Discomfort Scale-Dementia of Alzheimer Type (DS-DAT; range 0-27), End-Of-Life in Dementia-Comfort Assessment in Dying (EOLD-CAD; range 14-42) and an adapted version of the Mini-Suffering State Examination (MSSE; range 0-9), were used. Information on care, medical treatment and treatment decisions were also collected. RESULTS Twenty-four participants (median age 91 years; 23 females), were observed several times (mean of 4.3 observations (SD 2.6)), until they died. Most participants (n = 15) died from dehydration/cachexia and passed away quietly (n = 22). The mean PAINAD score was 1.0 (SD 1.7), DS-DAT 7.0 (SD 2.1), EOLD-CAD 35.1 (SD 1.7), and MSSE 2.0 (SD 1.7). All participants received morphine, six received antibiotics, and rehydration was prescribed once. CONCLUSION In these patients with dementia and expected death, a low symptom burden was observed with validated instruments, also in dehydrated patients without aggressive treatment. A good death is possible, but might be enhanced if the symptom burden is regularly assessed with validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.
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Affiliation(s)
- Maartje S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, P,O, Box 9600, 2300 RC Leiden, The Netherlands.
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Abstract
Increasing life span and lack of medication for prevention or treatment of progressive dementias will significantly increase the number of individuals with advanced dementia worldwide. Providing optimal care for them will stretch health care resources and will require evaluation of different treatment strategies. This paper is presenting measures that may be used in this patient population. Evaluation of global goals of palliative care may include measuring quality of life by QUALID scale, comfort by DS-DAT scale, and engagement by MPES scale. Symptom control may be achieved by measuring pain by PAINAD or PACSLAC scales, by evaluating behavioral symptoms and their management (agitation by SOAPD scale, apathy by AES scale and rejection of care by RTC-DAT scale), and by monitoring patients for dyspnea using RDOS scale. Outcomes of palliative care at the end of life may be evaluated by EOLD-CAD scale and by determining family satisfaction with care (EOLD-SWC). Items included in these scales, psychometric properties, and research use of these scales are described. It is hoped that information in this paper will stimulate research interest in this important area.
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van der Steen JT, Arcand M. Letter referring to the article "development and testing of a decision aid on goals of care for advanced dementia" by Einterz et al. J Am Med Dir Assoc 2014; 15:445. [PMID: 24721340 DOI: 10.1016/j.jamda.2014.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Marcel Arcand
- Department of Family Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
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Vandervoort A, Houttekier D, Vander Stichele R, van der Steen JT, Van den Block L. Quality of dying in nursing home residents dying with dementia: does advanced care planning matter? A nationwide postmortem study. PLoS One 2014; 9:e91130. [PMID: 24614884 PMCID: PMC3948949 DOI: 10.1371/journal.pone.0091130] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022] Open
Abstract
Background Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life, which is the case for many nursing home residents with dementia. We set out to investigate to what extent (1) advance care planning in the form of written advance patient directives and verbal communication with patient and/or relatives about future care and (2) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia. Methods Cross-sectional study of deaths (2010) using random cluster-sampling. Representative sample of nursing homes in Flanders, Belgium. Deaths of residents with dementia in a three-month period were reported; for each the nurse most involved in care, GP and closest relative completed structured questionnaires. Findings We identified 101 deaths of residents with dementia in 69 nursing homes (58% response rate). A written advance patient directive was present for 17.5%, GP-orders for 56.7%. Controlling for socio-demographic/clinical characteristics in multivariate regression analyses, chances of having a higher mean rating of emotional well-being (less fear and anxiety) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order (AOR 3.45; CI,1.1–11) than for those without either (AOR 2.99; CI,1.1–8.3). We found no association between verbal communication or having a GP order and quality of dying. Conclusion For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying. Where wishes are written, relatives report lower levels of emotional distress at the end of life. These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Jenny T. van der Steen
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- * E-mail:
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Boogaard JA, van Soest-Poortvliet MC, Anema JR, Achterberg WP, Hertogh CMPM, de Vet HCW, van der Steen JT. Feedback on end-of-life care in dementia: the study protocol of the FOLlow-up project. BMC Palliat Care 2013; 12:29. [PMID: 23924229 PMCID: PMC3751417 DOI: 10.1186/1472-684x-12-29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 08/01/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND End-of-life care in dementia in nursing homes is often found to be suboptimal. The Feedback on End-of-Life care in dementia (FOLlow-up) project tests the effectiveness of audit- and feedback to improve the quality of end-of-life care in dementia. METHODS/DESIGN Nursing homes systematically invite the family after death of a resident with dementia to provide feedback using the End-of-Life in Dementia (EOLD) - instruments. Two audit- and feedback strategies are designed and tested in a three-armed Randomized Controlled Trial (RCT): a generic feedback strategy using cumulative EOLD-scores of a group of patients and a patient specific feedback strategy using EOLD-scores on a patient level. A total of 18 nursing homes, three groups of six homes matched on size, geographic location, religious affiliation and availability of a palliative care unit were randomly assigned to an intervention group or the control group. The effect on quality of care and quality of dying and the barriers and facilitators of audit- and feedback in the nursing home setting are evaluated using mixed-method analyses. DISCUSSION The FOLlow-up project is the first study to assess and compare the effect of two audit- and feedback strategies to improve quality of care and quality of dying in dementia. The results contribute to the development of practice guidelines for nursing homes to monitor and improve care outcomes in the realm of end-of-life care in dementia. TRIAL REGISTRATION The Netherlands National Trial Register (NTR). TRIAL NUMBER NTR3942.
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Affiliation(s)
- Jannie A Boogaard
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
- Gerion, VU University Medical Center, Amsterdam, The Netherlands
| | - Mirjam C van Soest-Poortvliet
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
| | - Johannes R Anema
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
| | - Henrica C W de Vet
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
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