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Tay R, Tan JY, Lim B, Hum AY, Simpson J, Preston N. Factors associated with the place of death of persons with advanced dementia: A systematic review of international literature with meta-analysis. Palliat Med 2024:2692163241265231. [PMID: 39092850 DOI: 10.1177/02692163241265231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Many individuals with advanced dementia die in hospital, despite preferring home death. Existing evidence of factors affecting their place of death is inconsistent. To inform policies/practices for meeting needs/preferences, systematically establishing the evidence is pertinent, particularly given the exponential rise in advanced dementia prevalence. AIM To identify factors influencing where people with advanced dementia die. DESIGN AND DATA SOURCES This systematic review with meta-analysis was registered on PROSPERO (CRD42022366722). Medline, CINAHL, PsycINFO, SocINDEX and a grey literature database, Overton, were searched on 21/12/2022, supplemented by hand-searching/citation tracking. Papers reporting quantitative data on factors associated with place of death in advanced dementia were included and appraised using QualSyst. Data were analysed using random effects with the certainty of evidence determined using the GRADE criteria. RESULTS Thirty-three papers involving >5 million individuals (mean age = 89.2 years) were included. Long-term care setting deaths were relatively common but hospice deaths were rarer. Marriage's association with home death underscores social networks' importance, while younger age's and male gender's associations with hospital death demonstrate patients' and families' interdependency. Pneumonia/COPD's opposing effects on hospital deaths with cancer/functional impairment highlight the challenges of advanced dementia care. Unlike hospital/nursing home bed availability's lack of effect, capitated funding (fixed-amount-per-patient-per-period) decreased hospital death likelihood. CONCLUSION This comprehensive review of place of death determinants highlight the profound challenges of advanced dementia end-of-life care. Given that bed capacity did not affect place of death, a capitation-based, integrated palliative care model would appear more likely to meet patients' needs in a resource-constrained environment.
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Affiliation(s)
- RiYin Tay
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Dover Park Hospice, Singapore, Singapore
| | - Joyce Ys Tan
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - BinYan Lim
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Allyn Ym Hum
- The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jane Simpson
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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Smith C, Gill P, Baillie J. The clinical decision-making process involved in end of life care for people with dementia in primary care: A protocol paper. J Adv Nurs 2023. [PMID: 36779442 DOI: 10.1111/jan.15587] [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: 06/20/2022] [Revised: 12/22/2022] [Accepted: 01/20/2023] [Indexed: 02/14/2023]
Abstract
AIM This article is a report of a study protocol designed to explore what factors inform healthcare professionals' clinical decision-making when providing end of life care for people with dementia in primary care. DESIGN The proposed study will adopt a qualitative study design, utilizing an ethnographic approach. METHODS A mixed sample group of registered healthcare professionals, including district nurses, specialist nurses and general practitioners, will be purposively sampled and recruited from one health board in Wales, which will cover three settings in primary care. A multi-method approach will be utilized to provide rich data, including non-participant observation, semi-structured interviews, and review of key documents. Data will be managed using NVivo 12 and analysed thematically. Ethics approval was gained in April 2022. DISCUSSION Little is known about the end of life care decision-making process of healthcare professionals caring for people with dementia in primary care settings. This study will therefore address this pertinent gap. The study findings may also be transferable to healthcare professionals working in similar clinical settings across the UK. IMPACT It is anticipated that this study will inform the subsequent development of an intervention that can be used by healthcare professionals to support decision making and subsequently the provision of quality end of life care in primary care for people with dementia.
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Affiliation(s)
- Cathryn Smith
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Paul Gill
- Department of Nursing, Midwifery and Health, Faculty of Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Jessica Baillie
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
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Gonella S, Campagna S, Dimonte V. A Situation-Specific Theory of End-of-Life Communication in Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:869. [PMID: 36613191 PMCID: PMC9820248 DOI: 10.3390/ijerph20010869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/01/2022] [Accepted: 12/13/2022] [Indexed: 06/17/2023]
Abstract
High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.
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Affiliation(s)
- Silvia Gonella
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
| | - Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
| | - Valerio Dimonte
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
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Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol. BMC Palliat Care 2022; 21:202. [PMID: 36419147 PMCID: PMC9684772 DOI: 10.1186/s12904-022-01097-x] [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: 05/17/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia. METHODS/DESIGN This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners. DISCUSSION This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.
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Gonella S, Basso I, Dimonte V, Giulio PD. The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home. Int J Palliat Nurs 2022; 28:16-26. [PMID: 35094531 DOI: 10.12968/ijpn.2022.28.1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care. AIMS To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication. METHOD This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed. FINDINGS Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory. CONCLUSION Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.
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Affiliation(s)
- Silvia Gonella
- University of Roma Tor Vergata, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | | | - Valerio Dimonte
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy; University of Torino, Italy
| | - Paola Di Giulio
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy; University of Torino, Italy
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Armstrong MJ, Paulson HL, Maixner SM, Fields JA, Lunde AM, Boeve BF, Manning C, Galvin JE, Taylor AS, Li Z. Protocol for an observational cohort study identifying factors predicting accurately end of life in dementia with Lewy bodies and promoting quality end-of-life experiences: the PACE-DLB study. BMJ Open 2021; 11:e047554. [PMID: 34039578 PMCID: PMC8160156 DOI: 10.1136/bmjopen-2020-047554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias. Despite the fact that most individuals with DLB die from complications of the disease, little is known regarding what factors predict impending end of life or are associated with a quality end of life. METHODS AND ANALYSIS This is a multisite longitudinal cohort study. Participants are being recruited from five academic centres providing subspecialty DLB care and volunteers through the Lewy Body Dementia Association (not receiving specialty care). Dyads must be US residents, include individuals with a clinical diagnosis of DLB and at least moderate-to-severe dementia and include the primary caregiver, who must pass a brief cognitive screen. The first dyad was enrolled 25 February 2021; recruitment is ongoing. Dyads will attend study visits every 6 months through the end of life or 3 years. Study visits will occur in-person or virtually. Measures include demographics, DLB characteristics, caregiver considerations, quality of life and satisfaction with end-of-life experiences. For dyads where the individual with DLB dies, the caregiver will complete a final study visit 3 months after the death to assess grief, recovery and quality of the end-of-life experience. Terminal trend models will be employed to identify significant predictors of approaching end of life (death in the next 6 months). Similar models will assess caregiver factors (eg, grief, satisfaction with end-of-life experience) after the death of the individual with DLB. A qualitative descriptive analysis approach will evaluate interview transcripts regarding end-of-life experiences. ETHICS AND DISSEMINATION This study was approved by the University of Florida institutional review board (IRB202001438) and is listed on clinicaltrials.gov (NCT04829656). Data sharing follows National Institutes of Health policies. Study results will be disseminated via traditional scientific strategies (conferences, publications) and through collaborating with the Lewy Body Dementia Association, National Institute on Aging and other partnerships.
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Affiliation(s)
- Melissa J Armstrong
- Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Susan M Maixner
- Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie A Fields
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Angela M Lunde
- Psychiatry and Psychology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | | | - Carol Manning
- Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - James E Galvin
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Zhigang Li
- Biostatistics, University of Florida College of Medicine, Gainesville, Florida, USA
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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Gonella S, Basso I, Clari M, Dimonte V, Di Giulio P. A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home. Scand J Caring Sci 2020; 35:502-511. [PMID: 32343871 DOI: 10.1111/scs.12862] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/25/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly. AIM To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents. DESIGN A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted. RESULTS Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences. CONCLUSION This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.
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Affiliation(s)
- Silvia Gonella
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Roma, Italy.,Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Ines Basso
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Marco Clari
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
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9
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Hovland CA, Mallett CA. Dying With Dementia: Caregiver Observations of Their Family Members' Physical Decline and Behavioral or Psychological Changes During Their Last Days. OMEGA-JOURNAL OF DEATH AND DYING 2020; 84:653-672. [PMID: 32075522 DOI: 10.1177/0030222820906684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Family caregivers of older persons with dementia have significant challenges across many domains. These reported problems encountered over their caregiving time are for many reasons, but what makes the caretaking difficult is complicated by both the unknown nature of the dementia disease and the dying trajectory. While there are studies, primarily from health-care professionals, of this dying process and the last few weeks of life for older persons with dementia, much less is known directly from the family caregivers' perspectives and experiences. This qualitative study of 30 caregivers of family members aged 65 years and older who died with dementia-related diagnoses used in-depth qualitative interviews conducted over a 12-month period and directed content analysis to understand the data. The study asked what physical, behavioral, and psychological changes they observed and experienced during their family members' last weeks of life. Three primary themes were identified around behavioral and psychological changes: (a) they become different people, (b) did not recognize caregiver, and (c) wandering and getting lost; and two primary themes identified physical decline: (a) system started shutting down and (b) drastically diminished self-sufficiency. Implications for families and professionals are reviewed and discussed.
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Toscani F, Finetti S, Giunco F, Basso I, Rosa D, Pettenati F, Bussotti A, Villani D, Gentile S, Boncinelli L, Monti M, Spinsanti S, Piazza M, Charrier L, Di Giulio P. The last week of life of nursing home residents with advanced dementia: a retrospective study. BMC Palliat Care 2019; 18:117. [PMID: 31882007 PMCID: PMC6935223 DOI: 10.1186/s12904-019-0510-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/19/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.
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Affiliation(s)
- Franco Toscani
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Silvia Finetti
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Fabrizio Giunco
- Department of Health and Social Services Polo Lombardia 2, Don Carlo Gnocchi Foundation ONLUS, Via Palazzolo, 21, 20149 Milan, Italy
| | - Ines Basso
- Intensive Care Unit, SS Antonio e Biagio e Cesare Arrigo Hospital, Via Venezia, 16, 15121 Alessandria, Italy
| | - Debora Rosa
- University of Milan, section of Don Carlo Gnocchi Foundation, Via A. Capecelatro, 66, 20148 Milan, Italy
| | - Francesca Pettenati
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Alessandro Bussotti
- Agenzia Continuità Ospedale Territorio, Azienda Ospedaliero- Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Daniele Villani
- Neuro-Rehabilitation and Alzheimer Disease Evaluation Unit, Figlie di San Camillo Hospital, Via F. Filzi , 56, 26100 Cremona, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer Disease Evaluation Unit, Ancelle della Carità Hospital, Via G. Aselli, 14 Cremona, Italy
| | - Lorenzo Boncinelli
- Intensive Care Unit Geriatric, AOU Careggi-Largo Brambilla,3, 50134 Florence, Italy
| | - Massimo Monti
- Geriatric Institute Pio Albergo Trivulzio, via Trivulzio, 15, 20146 Milan, Italy
| | - Sandro Spinsanti
- Istituto Giano, Via Stazzo Quadro 7, 00060 Riano (Rm), Milan, Italy
| | - Massimo Piazza
- Italian Foundation of Leniterapia (FILE), Via San Niccolò, 1, 50125 Florence, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, 10126 Turin, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, 10126 Turin, Italy
- SUPSI, Manno, Switzerland
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Gonella S, Campagna S, Basso I, De Marinis MG, Di Giulio P. Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review. PATIENT EDUCATION AND COUNSELING 2019; 102:2134-2144. [PMID: 31278036 DOI: 10.1016/j.pec.2019.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 06/05/2019] [Accepted: 06/18/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents' likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs. METHODS Using the framework proposed by Arksey and O'Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study. RESULTS Three mechanisms were identified: a) promotion of family carers' understanding about their family member's health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents' preferences. CONCLUSION Family carers' understanding, shared decision-making, and knowledge of residents' preferences contribute to palliative-oriented care in NHs. PRACTICE IMPLICATIONS Discussions about end-of-life should take place early in a resident's disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.
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Affiliation(s)
- Silvia Gonella
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Via Montpellier 1, 00133, Roma, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Corso Bramante 88-90, 10126, Torino, Italy.
| | - Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Ines Basso
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Maria Grazia De Marinis
- Nursing Research Unit, University Campus Bio Medico of Roma, Via Alvaro del Portillo 200, 00128, Roma, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126, Torino, Italy
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12
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Daneau S, Bourbonnais A, Legault A. Surrogates' end-of-life decision-making process in nursing homes for residents with a neurocognitive disorder: An integrative review. Int J Older People Nurs 2019; 15:e12274. [PMID: 31612638 DOI: 10.1111/opn.12274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of this review is to analyse articles on the experience of surrogates who find themselves making end-of-life decisions for a relative with a major neurocognitive disorder in a nursing home. DESIGN An integrative review of the literature based on Whittemore and Knafl's method. DATA SOURCES This review used the CINAHL, PubMed, PsycInfo, Embase and Web of Science databases. A complementary search was also conducted via citation pearl searching, and the reference lists from the selected articles were manually verified. REVIEW METHOD The quality of the selected articles was assessed using the Crow Critical Appraisal Tool, and the data were extracted systematically and were then organised according to Mishel's uncertainty in illness theory. The data that did not correspond to any concept of the theory were excluded at this stage. Analysis was conducted using the method put forward by Miles, Huberman and Saldaña. RESULTS A total of 18 articles were selected: 11 qualitative, 5 quantitative and 1 using a mixed method, as well as 1 ethical argument. The subjects arising from the analysis of the articles were the types of decisions made, the support available for the surrogates, the role and involvement of the surrogates in the process and the factors that influence the decisions. CONCLUSION The results of this integrative review stimulate reflection on the needs of family members involved in making decisions, as well as on the nursing practice and research. Published literature is mainly from North America, and thus, more research is needed to better understand the impact of cultural and ethnic differences in the process, which was poorly covered by the existing literature. Also, exploring nurses' involvement in supporting surrogates may eventually better equip nurses for their interventions with surrogates. IMPLICATIONS FOR PRACTICE Describing the illness progression and the signification of palliative care to the resident with a NCD and their surrogate decision makers, as well as discussing end-of-life care preferences as early as possible are all nursing interventions that could potentially enhance surrogates' end-of-life decision-making process.
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Affiliation(s)
- Stéphanie Daneau
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Department of Nursing, Université du Québec à Trois-Rivières, Drummondville, QC, Canada
| | - Anne Bourbonnais
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Research Center of the Institut universitaire de gériatrie de Montréal, Montréal, QC, Canada
| | - Alain Legault
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
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Gonella S, Basso I, De Marinis MG, Campagna S, Di Giulio P. Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings. Palliat Med 2019; 33:589-606. [PMID: 30969160 DOI: 10.1177/0269216319840275] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase. AIM To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective. DESIGN Systematic review (PROSPERO no. 95581) with meta-aggregation method. DATA SOURCES Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied. RESULTS In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care. CONCLUSION The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.
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Affiliation(s)
- Silvia Gonella
- 1 Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy.,2 Azienda Ospedaliero Universitaria Città della Salute e della Scienza of Turin, Corso Bramante 88-90, 10126 Turin, Italy
| | - Ines Basso
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
| | - Maria Grazia De Marinis
- 4 Nursing Research Unit. University Campus Bio Medico of Rome, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Sara Campagna
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
| | - Paola Di Giulio
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
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14
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Gonella S, Basso I, Dimonte V, Martin B, Berchialla P, Campagna S, Di Giulio P. Association Between End-of-Life Conversations in Nursing Homes and End-of-Life Care Outcomes: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2019; 20:249-261. [PMID: 30470575 DOI: 10.1016/j.jamda.2018.10.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals-residents and health care professionals-family EOL conversations and EOL care outcomes. DESIGN Systematic review with meta-analysis. SETTING AND PARTICIPANTS Seven databases were searched in December 2017 to find studies that focused on health care professionals-residents (without oncologic disease) and health care professionals-family EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes. MEASURES Random effects meta-analyses with subsequent quality sensitivity analysis and meta-regression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias. RESULTS 16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionals-family EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio = 2.23, 95% confidence interval: 1.58-3.14). The overall effect of health care professionals-family EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the meta-regression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing life-sustaining treatments. No publication bias was detected (P = .4483). CONCLUSIONS/IMPLICATIONS This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decision-making process at EOL needs to be promoted.
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Affiliation(s)
- Silvia Gonella
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Roma, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.
| | - Ines Basso
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy; Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Barbara Martin
- Research and Third Mission Area, University of Torino, Torino, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Sara Campagna
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
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15
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Torres-Allepuz RM, Cantizano-Baldo I, Arias-Ruiz B, Pujol-Camacho M, Blasco-Rovira M, Espaulella-Panicot J. [Advanced dementia and critical decisions: An opportunity for advanced care planning]. Rev Esp Geriatr Gerontol 2019; 54:246-247. [PMID: 30737026 DOI: 10.1016/j.regg.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Rosa Maria Torres-Allepuz
- Residencia El Nadal, Vic, Barcelona, España; Hospital Universitari de la Santa Creu, Vic, Barcelona, España.
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16
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Di Giulio P, Finetti S, Giunco F, Basso I, Rosa D, Pettenati F, Bussotti A, Villani D, Gentile S, Boncinelli L, Monti M, Spinsanti S, Piazza M, Charrier L, Toscani F. The Impact of Nursing Homes Staff Education on End-of-Life Care in Residents With Advanced Dementia: A Quality Improvement Study. J Pain Symptom Manage 2019; 57:93-99. [PMID: 30315916 DOI: 10.1016/j.jpainsymman.2018.10.268] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT End-of-life care in nursing homes (NHs) needs improvement. We carried out a study in 29 NHs in the Lombardy Region (Italy). OBJECTIVES The objective of this study was to compare end-of-life care in NH residents with advanced dementia before and after an educational intervention aimed to improving palliative care. METHODS The intervention consisted of a seven-hour lecture, followed by two 3-hour meetings consisting of case discussions. The intervention was held in each NH and well attended by NH staff. This multicenter, comparative, observational study included up to 20 residents with advanced dementia from each NH: the last 10 who died before the intervention (preintervention group, 245 residents) and the first 10 who died at least three months after the intervention (postintervention group, 237 residents). Data for these residents were collected from records for 60 days and seven days before death. RESULTS The use of "comfort hydration" (<1000 mL/day subcutaneously) tended to increase from 16.9% to 26.8% in the postintervention group. The number of residents receiving a palliative approach for nutrition and hydration increased, though not significantly, from 24% preintervention to 31.5% postintervention. On the other hand, the proportion of tube-fed residents and residents receiving intravenous hydration decreased from 15.5% to 10.5%, and from 52% to 42%, respectively. Cardiopulmonary resuscitations decreased also from 52/245 (21%) to 18/237 (7.6%) cases (P = 0.002). CONCLUSION The short educational intervention modified some practices relevant to the quality of end-of-life care of advanced dementia patients in NHs, possibly raising and reinforcing beliefs and attitudes already largely present.
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Affiliation(s)
- Paola Di Giulio
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy; SUPSI, Manno, Switzerland
| | - Silvia Finetti
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
| | - Fabrizio Giunco
- Department of Health and Social Services Polo Lombardia 2, Don Carlo Gnocchi Foundation ONLUS, Milano, Italy
| | - Ines Basso
- Intensive Care Unit, SS Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Debora Rosa
- Nursing Degree Course, Section of Don Carlo Gnocchi Foundation, University of Milan, Milan, Italy
| | - Francesca Pettenati
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
| | - Alessandro Bussotti
- Agenzia Continuità Ospedale Territorio, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Daniele Villani
- Neuro-Rehabilitation and Alzheimer Disease Evaluation Unit, "Figlie di San Camillo" Hospital, Cremona, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer Disease Evaluation Unit, Ancelle della Carità Hospital, Cremona, Italy
| | | | - Massimo Monti
- Geriatric Institute "Pio Albergo Trivulzio", Milano, Italy
| | | | - Massimo Piazza
- Italian Foundation of Leniterapia (FILE), Firenze, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy.
| | - Franco Toscani
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
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17
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Dasch B, Bausewein C, Feddersen B. Place of death in patients with dementia and the association with comorbidities: a retrospective population-based observational study in Germany. BMC Palliat Care 2018; 17:80. [PMID: 29793476 PMCID: PMC5966860 DOI: 10.1186/s12904-018-0334-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Due to increasing life expectancy, more and more older people are suffering from dementia and comorbidities. To date, little information is available on place of death for dementia patients in Germany. In addition, the association of place of death and comorbidities is unknown. Methods A population-based cross-sectional survey was conducted in Westphalia–Lippe (Germany), based on the analysis of death certificates from 2011. Individuals with dementia ≥ 65 years were identified using the documented cause of death. In this context, all mentioned causes of death were included. In addition, ten selected comorbidities were also analyzed. The results were presented descriptively. Using multivariate logistic regression, place of death was analyzed for any association with comorbidities. Results A total of 10,364 death certificates were analyzed. Dementia was recorded in 1646 cases (15.9%; mean age 86.3 ± 6.9 years; 67.3% women). On average, 1.5 ± 1.0 selected comorbidities were present. Places of death were distributed as follows: home (19.9%), hospital (28.7%), palliative care unit (0.4%), nursing home (49.5%), hospice (0.9%), no details (0.7%). The death certificates documented cardiac failure in 43.6% of cases, pneumonia in 25.2%, and malignant tumour in 13.4%. An increased likelihood of dying in hospital compared to home or nursing home, respectively, was found for the following comorbidities (OR [95%-CI]): pneumonia (2.96 [2.01–4.35], p = 0.001); (2.38 [1.75–3.25], p = 0.001); renal failure (1.93 [1.26–2.97], p = 0.003); (1.65 [1.18–2.32], p = 0.003); and sepsis (13.73 [4.88–38.63], p = 0.001); (7.34 [4.21–12.78], p = 0.001). Conclusion The most common place of death in patients with dementia is the retirement or nursing home, followed by hospital and home. Specific comorbidities, such as pneumonia or sepsis, correlated with an increased probability of dying in hospital.
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Affiliation(s)
- Burkhard Dasch
- Department of Anesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH Bochum, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, Ludwig-Maximilians- University Munich, Munich, Germany
| | - Berend Feddersen
- Department of Palliative Medicine, Munich University Hospital, Ludwig-Maximilians- University Munich, Munich, Germany
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18
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Effect of music intervention on apathy in nursing home residents with dementia. Geriatr Nurs 2018; 39:471-476. [PMID: 29551546 DOI: 10.1016/j.gerinurse.2018.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/29/2023]
Abstract
This study examined the effectiveness of group music intervention in the treatment of nursing home residents with apathy. Apathy can clinically defined with a score of 40 or above on the apathy evaluation scale (AES). Seventy-seven residents were randomly assigned to the intervention or control group. The intervention group was given a music intervention programme, which included listening to traditional music, including nostalgic songs, and playing musical instruments three times a week, for a total of twelve weeks. Results demonstrated a decrease in apathy scores in the intervention group (z = 4.667, P <0.01), but not in the control group (z = -1.810, P > 0.05). Cognitive function, as assessed by Mini Mental State Examination (MMSE) score, was stable in the intervention group (t = 1.720, P > 0.05), but declined in the control group (t = -1.973, P <0.05). We conclude that music intervention has the potential to be an effective therapy for the treatment of apathy in the early stages of dementia.
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19
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Sampson EL, Candy B, Davis S, Gola AB, Harrington J, King M, Kupeli N, Leavey G, Moore K, Nazareth I, Omar RZ, Vickerstaff V, Jones L. Living and dying with advanced dementia: A prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018; 32:668-681. [PMID: 28922625 PMCID: PMC5987852 DOI: 10.1177/0269216317726443] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing number of people are dying with advanced dementia. Comfort and quality of life are key goals of care. AIMS To describe (1) physical and psychological symptoms, (2) health and social care service utilisation and (3) care at end of life in people with advanced dementia. DESIGN 9-month prospective cohort study. SETTING AND PARTICIPANTS Greater London, England, people with advanced dementia (Functional Assessment Staging Scale 6e and above) from 14 nursing homes or their own homes. MAIN OUTCOME MEASURES At study entry and monthly: prescriptions, Charlson Comorbidity Index, pressure sore risk/severity (Waterlow Scale/Stirling Scale, respectively), acute medical events, pain (Pain Assessment in Advanced Dementia), neuropsychiatric symptoms (Neuropsychiatric Inventory), quality of life (Quality of Life in Late-Stage Dementia Scale), resource use (Resource Utilization in Dementia Questionnaire and Client Services Receipt Inventory), presence/type of advance care plans, interventions, mortality, place of death and comfort (Symptom Management at End of Life in Dementia Scale). RESULTS Of 159 potential participants, 85 were recruited (62% alive at end of follow-up). Pain (11% at rest, 61% on movement) and significant agitation (54%) were common and persistent. Aspiration, dyspnoea, septicaemia and pneumonia were more frequent in those who died. In total, 76% had 'do not resuscitate' statements, less than 40% advance care plans. Most received primary care visits, there was little input from geriatrics or mental health but contact with emergency paramedics was common. CONCLUSION People with advanced dementia lived with distressing symptoms. Service provision was not tailored to their needs. Longitudinal multidisciplinary input could optimise symptom control and quality of life.
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Affiliation(s)
- Elizabeth L Sampson
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,2 Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Bridget Candy
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Sarah Davis
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Anna Buylova Gola
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jane Harrington
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michael King
- 3 Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Gerry Leavey
- 4 The Bamford Centre for Mental Health and Wellbeing, Ulster University, Coleraine, UK
| | - Kirsten Moore
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Irwin Nazareth
- 5 Department of Primary Care and Population Health, University College London, London, UK
| | - Rumana Z Omar
- 6 Department of Statistical Science, University College London, London, UK
| | - Victoria Vickerstaff
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,5 Department of Primary Care and Population Health, University College London, London, UK
| | - Louise Jones
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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20
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Janssens JFAM, de Kort SJ, Achterberg WP, Kurrle S, Kerse N, Cameron ID, Touwen DP. Medical and moral considerations regarding complex medical decisions in older patients with multimorbidity: a compact deliberation framework. BMC Geriatr 2018; 18:25. [PMID: 29370767 PMCID: PMC5785799 DOI: 10.1186/s12877-018-0707-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022] Open
Abstract
In health care for older adults, patients with multimorbidity usually receive the same interventions as those patients without multimorbidity. However, standard curative or life-sustaining treatment options have to be considered carefully in view of the maximally attainable result in older and frail patients. To guide such complex medical decisions, we present a compact deliberation framework that could assist physician(s) in charge of the medical treatment of a specific elderly patient to systematize his own thinking about treatment and decisional responsibilities, in case of an intercurrent disease. The framework includes four questions to be addressed when deciding on a single urgent standard curative or life-sustaining intervention in acute medical problems of an elderly patient with multimorbidity: 1) What is known about the patient’s aims and preferences? 2) Will the intervention be effective? 3) Will the intervention support the aims and preferences of the patient? 4) In view of the aims and preferences, will the risks and benefits be in balance? If all four considerations are answered favorably, the intervention will fit patient-centered and appropriate care for frail older patients with multimorbidity. Application to a patient case illustrates how our framework can improve the quality of the shared decision-making process in care for older people and helps clarify medical and moral considerations regarding how to appropriately treat the individual patient.
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Affiliation(s)
- Jeroen F A M Janssens
- Department of public health and primary care, Leiden University Medical Center, Postal adres: V06-P, Postbus 9600, 2300 RC, Leiden, The Netherlands. .,Novicare, Laan van Vredenoord 33, 2289 DA, Rijswijk, The Netherlands.
| | - Susanne J de Kort
- Topaz-Zuydtwijck, Aaltje Noordewierlaan 50, 2324 KS, Leiden, The Netherlands
| | - Wilco P Achterberg
- Department of public health and primary care, Leiden University Medical Center, The Netherlands, Postal adres: V06-P, Postbus 9600, 2300 RC, Leiden, The Netherlands
| | - Susan Kurrle
- Curran Ageing Research Unit, University of Sydney, Hornsby Ku-ring-gai Health Service, Hornsby, NSW, 2077, Australia
| | - Ngaire Kerse
- School of Population Health, University of Auckland, Tamaki Campus, Private Bag 92019, Auckland, 1001, New Zealand
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Dorothea P Touwen
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, The Netherlands, Postal adres: J1-P, Postbus 9600, 2300 RC, Leiden, The Netherlands
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21
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van der Steen JT, Di Giulio P, Giunco F, Monti M, Gentile S, Villani D, Finetti S, Pettenati F, Charrier L, Toscani F. Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort. Am J Hosp Palliat Care 2017; 35:423-430. [PMID: 28532225 PMCID: PMC5794105 DOI: 10.1177/1049909117709002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial. METHODS To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT). RESULTS Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5. CONCLUSIONS Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.
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Affiliation(s)
- 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
- Jenny T. van der Steen, PhD, Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- IRCCS Mario Negri Institute, Milano, Italy
| | - Fabrizio Giunco
- Istituto “L. Palazzolo”–Fondazione Don Gnocchi, Milano, Italy
| | - Massimo Monti
- Geriatric Institute “Pio Albergo Trivulzio”–Milano, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer’s Disease Evaluation Unit, “Ancelle della Carità” Hospital, Cremona, Italy
| | - Daniele Villani
- Neurorehabilitation and Alzheimer’s Disease Evaluation Unit, “Figlie di San Camillo” Hospital, Cremona, Italy
| | - Silvia Finetti
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
| | - Francesca Pettenati
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Franco Toscani
- Lino Maestroni Foundation–Palliative Medicine Research Institute, Cremona, Italy
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22
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Hendriks SA, Smalbrugge M, Hertogh CMPM, van der Steen JT. Changes in Care Goals and Treatment Orders Around the Occurrence of Health Problems and Hospital Transfers in Dementia: A Prospective Study. J Am Geriatr Soc 2016; 65:769-776. [DOI: 10.1111/jgs.14667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Simone A. Hendriks
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Martin Smalbrugge
- Department of General Practice & Elderly Care Medicine and 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 and EMGO+ Institute for Health and Care Research; VU University Medical Center; Amsterdam the Netherlands
| | - Jenny T. van der Steen
- Department of Primary Care and Community Care; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Public Health and Primary Care; Leiden University Medical Center; Leiden the Netherlands
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23
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Eicher S, Theill N, Geschwindner H, Moor C, Wettstein A, Bieri-Brüning G, Hock C, Martin M, Wolf H, Riese F. The last phase of life with dementia in Swiss nursing homes: the study protocol of the longitudinal and prospective ZULIDAD study. BMC Palliat Care 2016; 15:80. [PMID: 27557934 PMCID: PMC4997715 DOI: 10.1186/s12904-016-0151-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proportion of older people with advanced dementia who will die in nursing homes is constantly growing. However, little is known about the dying phase, the type of symptoms, the management of symptoms and the quality of life and dying in people with advanced dementia. The ZULIDAD (Zurich Life and Death with Advanced Dementia) study aims at extending the current scientific knowledge by providing first data from Switzerland. METHODS The ZULIDAD study employs a prospective design to study nursing home residents with advanced dementia for three years or until their death in eleven nursing homes in Zurich. Observational data from quarterly questionnaires for relatives and primary nurses is combined with data from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS). Special focus is put on 1) the cross-sectional analysis of baseline and post-mortem data regarding quality of life and quality of dying and how the perceptions of these measures differ between relatives and primary nurses, 2) the longitudinal analyses of established health outcome measures (e.g., EOLD, MSSE, BISAD, QUALID) in order to understand their trajectories and 3) international comparisons of cross-sectional and longitudinal data. DISCUSSION The ZULIDAD study is one of the few existing prospective studies on end-of-life care in dementia and it is the first prospective study to describe the situation in Switzerland. Its multi-perspective approach allows a comprehensive approximation to central health outcome measures at the end of life such as pain, suffering or quality of life. Providing insights into the current provision of care, it can serve as a basis for improving dementia end-of-life care in Switzerland and internationally.
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Affiliation(s)
- 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
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Heike Geschwindner
- City of Zurich Nursing Homes, Walchestrasse 31, 8021 Zurich, Switzerland
| | - Caroline Moor
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | - Albert Wettstein
- Center for Gerontology, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland
| | | | - Christoph Hock
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Mike Martin
- 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
- Department of Psychology, University of Zurich, Binzmuehlestrasse 14, 8050 Zurich, Switzerland
| | - Henrike Wolf
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
| | - Florian Riese
- University Research Priority Program “Dynamics of Healthy Aging”, University of Zurich, Andreasstrasse 15, 8050 Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Lenggstr. 31, 8032 Zurich, Switzerland
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24
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Hanson E, Hellström A, Sandvide Å, Jackson GA, MacRae R, Waugh A, Abreu W, Tolson D. The extended palliative phase of dementia – An integrative literature review. DEMENTIA 2016; 18:108-134. [PMID: 27460046 DOI: 10.1177/1471301216659797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.
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Affiliation(s)
- Elizabeth Hanson
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Amanda Hellström
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Åsa Sandvide
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
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25
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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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26
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Michel JP, Cha HB. Filling the Geriatric Education Gap Around the World. J Am Med Dir Assoc 2015; 16:1010-3. [DOI: 10.1016/j.jamda.2015.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 12/13/2022]
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27
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Expectation Conversations About the Very Predictable Events in Advanced Dementia. J Am Med Dir Assoc 2015; 16:724-7. [DOI: 10.1016/j.jamda.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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