Integrating palliative care in the nursing home: an interprofessional opportunity

Changes in Advance Care Planning for Nursing Home Residents During the COVID-19 Pandemic

OBJECTIVE

Describe the care preference changes among nursing home residents receiving proactive Advance Care Planning (ACP) conversations from health care practitioners during the COVID-19 pandemic.

DESIGN

Retrospective chart review.

SETTING AND PARTICIPANTS

Nursing home residents (n = 963) or their surrogate decision makers had at least 1 ACP conversation with a primary health care practitioner between April 1, 2020, and May 30, 2020, and made decisions of any changes in code status and hospitalization preferences.

METHODS

Health care practitioners conducted ACP conversations proactively with residents or their surrogate decision makers at 15 nursing homes in a metropolitan area of the southwestern United States between April 1, 2020, and May 30, 2020. ACP conversations reviewed code status and goals of care including Do Not Hospitalize (DNH) care preference. Resident age, gender, code status, and DNH choice before and after the ACP conversations were documented. Descriptive data analyses identified significant changes in resident care preferences before and after ACP conversations.

RESULTS

Before the most recent ACP discussion, 361 residents were full code status and the rest were Out of Hospital Do Not Resuscitate (DNR). Of the individuals with Out of Hospital DNR, 188 residents also chose DNH. After the ACP conversation, 88 residents opted to change from full code status to Out of Hospital DNR, thereby increasing the percentage of residents with Out of Hospital DNR from 63% to 72%. Almost half of the residents decided to keep or change to the DNH care option after the ACP conversation.

CONCLUSION AND IMPLICATIONS

Proactive ACP conversations during COVID-19 increased DNH from less than a quarter to almost half among the nursing home residents. Out of Hospital DNR increased by 9%. It is important for all health care practitioners to proactively review ACP with nursing home residents and their surrogate decision makers during a pandemic, thereby ensuring care consistent with personal goals of care and avoiding unnecessary hospitalizations.

Medication use in aged care residents in the last year of life: A scoping review

BACKGROUND

A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life.

AIM

The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision.

DESIGN

A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018.

DATA SOURCES

We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life.

RESULTS

A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications.

CONCLUSION

Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.

A framework for cross-cultural development and implementation of complex interventions to improve palliative care in nursing homes: the PACE steps to success programme

BACKGROUND

The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar.

METHODS

The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support.

RESULTS

Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1-3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention.

CONCLUSIONS

There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.

Advance Care Planning in Chinese Seniors: Cultural Perspectives

In traditional Chinese culture, death was sensitive and mentioning it was sacrilegious and to be avoided. Many Chinese families object to telling the patient a "bad" diagnosis or prognosis, which may hinder the chance in advance care planning (ACP) discussion. While death remains an inevitable consequence of being born, as such, it is important that human beings recognize its inevitability and plan ahead of a good death. Advance care planning enables patients to assert their care preferences in the event that they are unable to make their own medical decisions. In China, a rapidly aging demographic presents additional challenges to quality end-of-life care. The adoption of palliative care in China has been slow, with a curative approach dominating health-care strategies. In this article, we would summarize China's current situation in population aging, palliative care development, and Chinese cultural values on death and dying and review the advance directive and end-of-life care preferences among Chinese elderly patients. Current literature recommended the use of indirect communication approaches to determine Chinese seniors' readiness. In individual practice, using depersonalized communication strategies to initiate the discussion was recommended to determine older Chinese seniors' readiness.

Drug Prescriptions in Nursing Home Residents during their Last 6 Months of Life: Data from the IQUARE Study

OBJECTIVE

To assess the drug prescriptions of nursing home (NH) residents during the 6 months prior to their death, and the impact of the recognition of « life expectancy lower than 6 months » by the NH staff on the prescriptions.

DESIGN

Prospective study.

SETTING

175 nursing homes in France.

PARTICIPANTS

6275 residents were included from May to June 2011.

MEASUREMENTS

The initial drug prescriptions of the residents who deceased within 6 months were compared with those who did not decease. Among the residents deceased within 6 months, the drug prescriptions were compared between the residents who were «considered at the end of their life» and those who were not. Potentially inappropriate prescriptions (PIP) were analyzed using Laroche criteria and a list of therapies considered as inappropriate at the end of life.

RESULTS

498 residents (7.9%) died within 6 months after their inclusion: they had significantly more therapies (8.3 ± 3.8 vs. 7.9 ± 3.5, p=0.048) than non-deceased people. Sixty-one of the residents deceased within 6 months were considered by the NH staff as «end of life residents » (12.2%). They received significantly less drugs (6.4 ± 4.2 vs 8.5 ± 3.6, p<0.001) than NH's residents not identified at the end of their life. They had a more frequent prescription of opioids (p<0.001), and less antipsychotics (p<0.001), lipid-lowering drugs (p=0.006), or antihypertensive therapies (p<0.01). They also received significantly less PIP (59.0% received at least one inappropriate prescription, vs. 87.2%, p<0.001).

CONCLUSION

An important proportion of nursing home residents received PIP. The quality of prescriptions in patients identified at the end of their life seems to improve, but more than half still receive inappropriate drugs. Special attention in prescribing should be given to these patients presenting a high risk of adverse events.

Integrating Quality Palliative and End-of-Life Care into the Geriatric Assessment: Opportunities and Challenges

This article provides an overview of how integrating quality palliative and end-of-life care into geriatric assessment can be a tremendous benefit to older adult patients and their families. Although the quality of palliative and end-of-life care for older adults has improved greatly, there are still many opportunities to improve the quality of life and function for older adult patients in the last few years of their life. More clinical expertise in comprehensive palliative and end-of-life care must be developed and maintained. There also must be greater focus and more direct reimbursement developed for physicians and health system providers.

Caring About Residents' Experiences and Symptoms (CARES) Program: A Model of Palliative Care Consultation in the Nursing Home

OBJECTIVES

To describe the CARES program, a model of palliative care for nursing home residents.

DESIGN

Descriptive analysis of the Caring About Residents' Experiences and Symptoms (CARES) Program that provides palliative care services to nursing home residents.

PROGRAM EVALUATION

The CARES Program serves as an example of collaborative efforts to meet community needs. To evaluate the program, we document the services provided as well as process outcomes (changes to care plans, hospitalizations, location of death, and hospice utilization) for residents referred.

RESULTS

170 nursing home residents were seen by CARES Program between February 2013 to December 2015, 48% for skilled services, and 52% for long term care. Majority of referrals were for goals of care and concurrent symptom management. Following consultation, 67% of residents had a change in code status. Of residents desiring a palliative course 90% were never hospitalized. Overall, 53% of residents died; and those in long term care dying more often with hospice.

CONCLUSION

The CARES program of palliative consultation addresses the needs of nursing home residents. The model has potential to be reproducible in in other communities.