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End-of-life care practices in Korean nursing homes: a national survey. Int J Nurs Stud 2022; 129:104173. [DOI: 10.1016/j.ijnurstu.2022.104173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
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Sedhom R, Kuo PL, Gupta A, Smith TJ, Chino F, Carducci MA, Bandeen-Roche K. Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities? J Geriatr Oncol 2020; 12:361-367. [PMID: 33121909 DOI: 10.1016/j.jgo.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Place of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer. METHODS Deidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. RESULTS From 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%. CONCLUSION Hospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America.
| | - Pei-Lun Kuo
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Thomas J Smith
- Department of Palliative Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Michael A Carducci
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, United States of America
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Werner P, Schiffman IK. Nursing home staff members' attitudes regarding advance care planning: relationships with different types of knowledge. Aging Clin Exp Res 2020; 32:2091-2098. [PMID: 31686389 DOI: 10.1007/s40520-019-01398-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advanced care planning (ACP) is an essential component of quality palliative care in nursing homes. Despite the benefits associated with ACP in nursing homes, completion rates are low. Staff members' knowledge and attitudes toward ACP were found to be main determinants of ACP completion. AIMS To assess nursing home staff members' attitudes towards ACP and their association to different types of knowledge. METHODS A convenience sample of 138 nursing home staff members (69% female, 53% non-Jewish, 46% nurses) who reported having heard the terms advanced directives and durable power of attorney completed a structured questionnaire assessing attitudes toward ACP, subjective knowledge, and three types of objective knowledge (declarative, legal and procedural) regarding ACP, as well as socio-demographic and professional factors. RESULTS Participants expressed positive attitudes toward formal and informal aspect of ACP, although their subjective and objective knowledge in the topic was moderate. Hierarchical regression analyses revealed that the three dimensions of objective knowledge improved significantly the participants' attitude scores. DISCUSSION There is a need to integrate different types of knowledge in educational programs provided to nursing home staff members to improve their involvement in ACP initiatives with residents and family members.
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Affiliation(s)
- Perla Werner
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa, Israel.
| | - Ile Kermel Schiffman
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa, Israel
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Schwartz ML, Lima JC, Clark MA, Miller SC. End-of-Life Culture Change Practices in U.S. Nursing Homes in 2016/2017. J Pain Symptom Manage 2019; 57:525-534. [PMID: 30578935 PMCID: PMC6668722 DOI: 10.1016/j.jpainsymman.2018.12.330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/06/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022]
Abstract
CONTEXT The nursing home (NH) culture change (CC) movement, which emphasizes person-centered care, is particularly relevant to meeting the unique needs of residents near the end of life. OBJECTIVES We aimed to evaluate the NH-reported adoption of person-centered end-of-life culture change (EOL-CC) practices and identify NH characteristics associated with greater adoption. METHODS We used NH and state policy data for 1358 NHs completing a nationally representative 2016/17 NH Culture Change Survey. An 18-point EOL-CC score was created by summarizing responses from six survey items related to practices for residents who were dying/had died. NHs were divided into quartiles reflecting their EOL-CC score, and multivariable ordered logistic regression was used to identify NH characteristics associated with having higher (quartile) scores. RESULTS The mean EOL-CC score was 13.7 (SD = 3.0). Correlates of higher scores differed from those previously found for non-EOL-CC practices. Higher NH leadership scores and nonprofit status were consistently associated with higher EOL-CC scores. For example, a three-point leadership score increase was associated with higher odds of an NH performing in the top EOL-CC quartile (odds ratio [OR] = 2.0, 95% CI: 1.82-2.30), whereas for-profit status was associated with lower odds (OR = 0.7, 95% CI: 0.49-0.90). The availability of palliative care consults was associated with a greater likelihood of EOL-CC scores above the median (OR = 1.5, 95% CI: 1.10-1.93), but not in the top or bottom quartile. CONCLUSION NH-reported adoption of EOL-CC practices varies, and the presence of palliative care consults in NHs explains only some of this variation. Findings support the importance of evaluating EOL-CC practices separately from other culture change practices.
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Affiliation(s)
- Margot L Schwartz
- Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Julie C Lima
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Melissa A Clark
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Rodriquez J, Boerner K. Social and organizational practices that influence hospice utilization in nursing homes. J Aging Stud 2018; 46:76-81. [PMID: 30100120 DOI: 10.1016/j.jaging.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/07/2018] [Accepted: 06/23/2018] [Indexed: 11/18/2022]
Abstract
Hospice has grown considerably but the likelihood that someone gets hospice depends on social and organizational practices. This article shows how staff beliefs and work routines influenced hospice utilization in two nursing homes. In one, 76% of residents died on hospice and in the other 24% did. Staff identified barriers to hospice including families who saw hospice as giving up and gaps in the reimbursement system. At the high-hospice nursing home, staff said hospice care extended beyond what they provided on their own. At the low-hospice nursing home, an influential group said hospice was essentially the same as their own end-of-life care and therefore needlessly duplicative. Staff at the high-hospice nursing home proactively approached families about hospice, whereas staff at the low-hospice nursing home took a reactive approach, getting hospice when families asked for it. Findings demonstrate how staff beliefs and practices regarding hospice shape end-of-life care in nursing homes.
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Affiliation(s)
- Jason Rodriquez
- Department of Sociology, University of Massachusetts - Boston, Boston, MA, United States.
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts - Boston, Boston, MA, United States.
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Norton SA, Ladwig S, Caprio TV, Quill TE, Temkin-Greener H. Staff Experiences Forming and Sustaining Palliative Care Teams in Nursing Homes. THE GERONTOLOGIST 2018; 58:e218-e225. [DOI: 10.1093/geront/gnx201] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 01/25/2023] Open
Affiliation(s)
| | - Susan Ladwig
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Thomas V Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Timothy E Quill
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Specialty Palliative Care Consultations for Nursing Home Residents With Dementia. J Pain Symptom Manage 2017; 54:9-16.e5. [PMID: 28438589 PMCID: PMC5663286 DOI: 10.1016/j.jpainsymman.2017.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/20/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT U.S. nursing home (NH) residents with dementia have limited access to specialty palliative care beyond Medicare hospice. OBJECTIVES The objective of this study was to examine the value of expanded palliative care access for NH residents with moderate-to-very severe dementia. METHODS We merged palliative care consultation data in 31 NHs in two states to Medicare data to identify residents with consultations, moderate-to-very severe dementia, and deaths in 2006-2010. Initial palliative consultations were identified as occurring later and earlier (1-30 days and 31-180 days before death, respectively). Three controls for each consultation recipient were selected using propensity score matching. Weighted multivariate analyses evaluated the effect of consultations on hospital or acute care use seven and 30 days before death and on (potentially) burdensome transitions (i.e., hospital or hospice admission three days before death or two plus acute care transitions 30 days before death). RESULTS With earlier consultation (vs. no consultation), hospitalization rates in the seven days before death were on average 13.2 percentage points lower (95% confidence interval [CI] -21.8%, -4.7%) and with later consultation 5.9 percentage points lower (95% CI -13.7%, +4.9%). For earlier consultations (vs. no consultations), rates were 18.4 percentage points lower (95% CI -28.5%, -8.4%) for hospitalizations and 11.9 lower (95% CI -20.7%, -3.1%) for emergency room visits 30 days before death; they were 20.2 percentage points lower (95% CI -28.5%, -12.0%) for burdensome transitions. CONCLUSION Consultations appear to reduce acute care use and (potentially) burdensome transitions for dying residents with dementia. Reductions were greater when consultations were earlier.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Julie C Lima
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA; Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York, USA
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island, USA; Hope Hospice and Palliative Care, Providence, Rhode Island, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA
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Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings. Contemp Clin Trials 2017; 56:1-8. [PMID: 28315478 DOI: 10.1016/j.cct.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. METHODS/DESIGN This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. DISCUSSION Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions. J Am Geriatr Soc 2016; 64:2280-2287. [PMID: 27641157 DOI: 10.1111/jgs.14469] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end-of-life care transitions and acute care use DESIGN: Propensity score-matched retrospective cohort study. SETTING Forty-six NHs in two states. PARTICIPANTS Nursing home residents who died from 2006 to 2010 stratified according to days between initial consultation and death (≤7, 8-30, 31-60, 61-180). Propensity score matching identified three controls (n = 1,174) according to strata for each consultation recipient (n = 477). MEASUREMENTS Outcomes were hospitalizations in the last 7, 30, and 60 days of life; emergency department (ED) visits in the last 30 and 60 days; and any potentially burdensome care transition, defined as hospitalization or hospice admission within 3 days of death or two or more hospitalizations or ED visits within 30 days. Weighted multivariate logistic regression analyses were used to evaluate outcomes. RESULTS Residents with consultations had lower rates of hospitalization than controls, with rates lowest when initial consultations were furthest from death. For instance, in residents with initial consultations 8 to 30 days before death, the adjusted hospitalization rate in the last 7 days of life was 11.1% (95% confidence interval (CI) = 9.8-12.4%), vs 22.0% (95% CI = 20.6-23.4%) in controls, although in those with initial consultations 61 to 180 days before death, rates were 6.9% (95% CI = 5.5-8.4%), vs 22.9% (95% CI = 20.5-25.4%). Potentially burdensome transition rates were lower when consultations were 61 to 180 days before death (16.2%, 95% CI = 13.7-18.6%), vs 28.2% (95% CI = 25.8-30.6%) for controls. CONCLUSION Palliative care consultations improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, & Practice, Brown University, Providence, Rhode Island.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Julie C Lima
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York.,Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island.,Hope Hospice & Palliative Care, Providence, Rhode Island
| | | | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina.,Center for Aging and Health, University of North Carolina, Chapel Hill, North Carolina.,Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
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10
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Temkin-Greener H, Li Q, Li Y, Segelman M, Mukamel DB. End-of-Life Care in Nursing Homes: From Care Processes to Quality. J Palliat Med 2016; 19:1304-1311. [PMID: 27529742 DOI: 10.1089/jpm.2016.0093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. DESIGN AND METHODS We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. RESULTS Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice. CONCLUSIONS Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.
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Affiliation(s)
- Helena Temkin-Greener
- 1 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry , Rochester, New York
| | - Qinghua Li
- 2 RTI International, Waltham, Massachusetts
| | - Yue Li
- 1 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry , Rochester, New York
| | | | - Dana B Mukamel
- 3 Department of Medicine, University of California , Irvine, California
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Abele P, Morley JE. Advance Directives: The Key to a Good Death? J Am Med Dir Assoc 2016; 17:279-83. [PMID: 26952570 DOI: 10.1016/j.jamda.2016.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Patricia Abele
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO; Division of Endocrinology, Saint Louis University School of Medicine, St Louis, MO.
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Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2015; 43:1964-77. [PMID: 26154929 DOI: 10.1097/ccm.0000000000001131] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. DATA SOURCES A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." DATA EXTRACTION AND SYNTHESIS We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. CONCLUSIONS Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.
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Unroe KT, Cagle JG, Lane KA, Callahan CM, Miller SC. Nursing Home Staff Palliative Care Knowledge and Practices: Results of a Large Survey of Frontline Workers. J Pain Symptom Manage 2015; 50:622-9. [PMID: 26150325 PMCID: PMC4755479 DOI: 10.1016/j.jpainsymman.2015.06.006] [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] [Received: 11/24/2014] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Deficits in quality end-of-life care for nursing home (NH) residents are well known. Palliative care is promoted as an approach to improve quality. The Palliative Care Survey (PCS) is designed to measure NH staff palliative care knowledge and practice. OBJECTIVES To comparing palliative care knowledge and practices across NH staff roles using the PCS, and to examine relationships between facility characteristics and PCS scores. METHODS The PCS was administered to frontline NH staff-certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), and social workers (SWs)-in 51 facilities in 2012. Descriptive statistics were calculated by job role. Linear mixed effects models were used to identify facility and individual factors associated with palliative care practice and knowledge. RESULTS The analytic sample included 1200 surveys. CNAs had significantly lower practice and knowledge scores compared to LPNs, RNs, and SWs (P < 0.05). LPNs had significantly lower psychological, end-of-life, and total knowledge scores than RNs (P < 0.05 for all). Although knowledge about physical symptoms was uniformly high, end-of-life knowledge was notably low for all staff. A one-point higher facility star rating was significantly associated with a 0.06 increase in family communication score (P = 0.003; 95% CI: 0.02-0.09; SE = 0.02). Higher penetration of hospice in the NH was associated with higher end-of-life knowledge (P = 0.003; parameter estimate = 0.006; 95% CI: 0.002-0.010; SE = 0.002). Sixty-two percent of respondents stated that, with additional training, they would be interested in being leaders in palliative care. CONCLUSION Given observed differences in palliative care practice and knowledge scores by staff training, it appears the PCS is a useful tool to assess NH staff. Low end-of-life knowledge scores represent an important target for quality improvement.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - John G Cagle
- University of Maryland-Baltimore School of Social Work, Baltimore, Maryland, USA
| | - Kathleen A Lane
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Cai X, Robinson J, Muehlschlegel S, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 2015; 23:131-41. [PMID: 25990137 PMCID: PMC4816524 DOI: 10.1007/s12028-015-0149-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Affiliation(s)
- Xuemei Cai
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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15
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Kaehr E, Visvanathan R, Malmstrom TK, Morley JE. Frailty in Nursing Homes: The FRAIL-NH Scale. J Am Med Dir Assoc 2015; 16:87-9. [DOI: 10.1016/j.jamda.2014.12.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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