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Carpenter JG, Murthi J, Langford M, Lopez RP. A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project. J Hosp Palliat Nurs 2024; 26:205-211. [PMID: 38529958 PMCID: PMC11233246 DOI: 10.1097/njh.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.
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Lemoyne S, Van Bastelaere J, Nackaerts S, Verdonck P, Monsieurs K, Schnaubelt S. Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study. Front Med (Lausanne) 2024; 11:1396858. [PMID: 38962739 PMCID: PMC11220277 DOI: 10.3389/fmed.2024.1396858] [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: 03/06/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Introduction A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness. Methods An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics. Results A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%). Discussion and conclusion EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.
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Affiliation(s)
- Sabine Lemoyne
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
| | - Joanne Van Bastelaere
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Department of Public Health and Primary Care, Catholic University of Leuven, Leuven, Belgium
| | - Sofie Nackaerts
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
| | - Philip Verdonck
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
| | - Koenraad Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
| | - Sebastian Schnaubelt
- Department of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Antwerp, Belgium
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
- Emergency Medical Service Vienna, Vienna, Austria
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Stephens CE, Tay D, Iacob E, Hollinghaus M, Goodwin R, Kelly B, Smith K, Ellington L, Utz R, Ornstein K. Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family. Palliat Med Rep 2023; 4:308-315. [PMID: 38026144 PMCID: PMC10664558 DOI: 10.1089/pmr.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 12/01/2023] Open
Abstract
Background Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL). Objective To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405). Methods Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424). Results Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001). Conclusions Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.
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Affiliation(s)
| | - Djin Tay
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Eli Iacob
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Michael Hollinghaus
- Kem C. Gardner Policy Institute, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Goodwin
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Brenna Kelly
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Ken Smith
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
- College of Social & Behavioral Sciences, Department of Family and Consumer Studies, University of Utah, Salt Lake City, Utah, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Utz
- College of Social & Behavioral Sciences, Department of Sociology, University of Utah, Salt Lake City, Utah, USA
| | - Katherine Ornstein
- Johns Hopkins School of Nursing, Center for Equity in Aging, Baltimore, Maryland, USA
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Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-130. [PMID: 37916580 DOI: 10.3310/klpw6338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Adam Lee Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
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Singh S, Dafoe A, Lahoff D, Tropeano L, Owens B, Nielsen E, Cagle J, Lum HD, Dorsey Holliman B, Fischer S. Pilot Trial of a Social Work Intervention to Provide Palliative Care for Adults with Cancer in Skilled Nursing Facilities. J Palliat Med 2022; 26:527-538. [PMID: 36409676 DOI: 10.1089/jpm.2022.0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Hospitalized patients with cancer and their caregivers discharged to skilled nursing facilities (SNFs) have unmet palliative care needs. Objective: To determine feasibility and acceptability of Assessing and Listening to Individual Goals and Needs (ALIGN), a palliative care social worker (PCSW) intervention, for older adults and their caregivers in SNFs. Design: Single-arm, single-site pilot study. Predefined feasibility goals were >70% intervention completion and study retention rates (postintervention outcomes completed at one week). Setting/Subjects: Twenty-three patients with cancer and their 21 caregivers discharged to 12 SNFs posthospitalization. Measurements: Primary outcomes were feasibility and acceptability. Exploratory patient and caregiver-reported outcomes, including goals of care were collected at baseline and one week postintervention. Health care utilization, mortality, and hospice utilization was collected at the six-month follow-up. Results: Of 73 patients screened, 35 (48%) were eligible and 23 (66%) patients and 21 caregivers enrolled. Eighteen (78%) patients completed the intervention and 10 (44%) patients and 13 (62%) caregivers provided follow-up outcomes. Average age of patients was 73, and 19 (83%) had stage III or IV cancer. Average age of caregivers was 55. Eight (44%) patients' preferences changed to prefer less aggressive care. Nineteen (83%) patients died during or shortly after intervention completion. Qualitative feedback from participant and SNF staff interviews supported high acceptability. PCSW involvement increased illness understanding and patient engagement with advance care planning. SNF staff valued increased palliative support. Conclusions: Intervention completion was >70%, however, not study retention due to higher-than-expected mortality. Future study should account for high mortality and examine whether ALIGN can better prepare surrogate decision makers and enhance the ability of SNFs to address changing goals of care. Clinical Trial Registration Number NCT04882111.
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Affiliation(s)
- Sarguni Singh
- Division of Hospital Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, USA
| | | | | | - Bree Owens
- The Holding Group, Denver, Colorado, USA
| | | | - John Cagle
- University of Maryland School of Social Work, Baltimore, Maryland, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Brooke Dorsey Holliman
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, USA
| | - Stacy Fischer
- Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado, USA
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Kazazian K, Ng D, Swallow CJ. Impact of the coronavirus disease 2019 pandemic on delivery of and models for supportive and palliative care for oncology patients. Curr Opin Support Palliat Care 2022; 16:130-137. [PMID: 35862890 PMCID: PMC9451606 DOI: 10.1097/spc.0000000000000606] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Supportive and palliative care services have been an important component of the overall COVID-19 pandemic response. However, significant changes in the provision and models of care were needed in order to optimize the care delivered to vulnerable cancer patients. This review discusses the evolution of palliative and supportive care service in response to the pandemic, and highlights remaining challenges. RECENT FINDINGS Direct competition for resources, as well as widespread implementation of safety measures resulted in major shifts in the mode of assessment and communication with cancer patients by supportive care teams. Telemedicine/virtual consultation and follow-up visits became an integral strategy, with high uptake and satisfaction amongst patients, families and providers. However, inequities in access to the required technologies were sometimes exposed. Hospice/palliative care unit (PCU) bed occupancy declined markedly because of restrictive visitation policies. Collection of patient-reported outcome (PRO) data was suspended in many cancer centers, with resulting under-recognition of anxiety and depression in ambulatory patients. As in many other areas, disparities in delivery of supportive and palliative care were magnified by the pandemic. SUMMARY Virtual care platforms have been widely adopted and will continue to be used to include a wider circle of family/friends and care providers in the provision of palliative and supportive care. To facilitate equitable delivery of supportive care within a pandemic, further research and resources are needed to train and support generalists and palliative care providers. Strategies to successfully collect PROs from all patients in a virtual manner must be developed and implemented.
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Affiliation(s)
- Karineh Kazazian
- Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and Mount Sinai Hospital
- Division of General Surgery, Mount Sinai Hospital, Sinai Health System
- Department of Surgery, University of Toronto
| | - Deanna Ng
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Carol J. Swallow
- Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and Mount Sinai Hospital
- Division of General Surgery, Mount Sinai Hospital, Sinai Health System
- Department of Surgery, University of Toronto
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
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Estrada LV, Harrison JM, Dick AW, Luchsinger JA, Dhingra L, Stone PW. Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents. J Palliat Med 2022; 25:1228-1235. [PMID: 35143358 PMCID: PMC9347389 DOI: 10.1089/jpm.2021.0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.
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Affiliation(s)
- Leah V. Estrada
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
| | | | | | - José A. Luchsinger
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
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Ninteau K, Bishop CE. Nursing Home Palliative Care during the Pandemic: Directions for the Future. Innov Aging 2022; 6:igac030. [PMID: 35832204 PMCID: PMC9273407 DOI: 10.1093/geroni/igac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers. Research Design and Methods For this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Results Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Discussion and Implications Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.
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Affiliation(s)
- Kacy Ninteau
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christine E Bishop
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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Ersek M, Unroe KT, Carpenter JG, Cagle JG, Stephens CE, Stevenson DG. High-Quality Nursing Home and Palliative Care-One and the Same. J Am Med Dir Assoc 2022; 23:247-252. [PMID: 34953767 PMCID: PMC8821139 DOI: 10.1016/j.jamda.2021.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023]
Abstract
Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.
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Affiliation(s)
- Mary Ersek
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Joan G Carpenter
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA; University of Maryland School of Nursing, Baltimore, MD, USA
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
| | | | - David G Stevenson
- Veterans Affairs Tennessee Valley Healthcare System, Murfreesboro, TN, USA; Vanderbilt School of Medicine, Nashville, TN, USA
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10
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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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Baxter KE, Kochar S, Williams C, Blackman C, Himmelvo J. Development of a Palliative Telehealth Pilot to Meet the Needs of the Nursing Home Population. J Hosp Palliat Nurs 2021; 23:478-483. [PMID: 34225341 DOI: 10.1097/njh.0000000000000784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many older adults will spend their final days in a skilled nursing facility because of multiple complex conditions. Patients with unclear goals of care are at higher risk of rehospitalization and burdensome care at end of life. Palliative care has been shown to improve outcomes for this patient population; however, access is limited because of the small number of boarded specialists nationwide. Telehealth offers the ability to expand the reach of palliative care to both underserved geographies and community settings. This quality improvement pilot project details the development and implementation of a telehealth palliative care program available to nursing home residents. Eight nursing homes, in the New England region of the United States, participated in the 4-month pilot. The palliative telehealth program offered real-time access to a palliative care specialist able to provide symptom management, goals-of-care discussions, and Medical Orders for Life-Sustaining Treatment completion. The pilot shows promising outcomes including code status change, Medical Order for Life-Sustaining Treatment form completion, and reduced hospitalizations supporting the benefit of comprehensive goals-of-care discussions for frail older adults living in a nursing home. As health care moves into the digital age, telemedicine plays a large role in the delivery of essential patient care. Provision of palliative specialists by telehealth allows the opportunity to address the unmet needs of this frail population.
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Kutney-Lee A, Smith D, Griffin H, Kinder D, Carpenter J, Thorpe J, Murray A, Shreve S, Ersek M. Quality of end-of-life care for Vietnam-era Veterans: Implications for practice and policy. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100494. [PMID: 33992224 DOI: 10.1016/j.hjdsi.2020.100494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 09/04/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA's response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. METHODS Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between fiscal year 2013-2017. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. RESULTS Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. CONCLUSIONS Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. IMPLICATIONS Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.
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Affiliation(s)
- Ann Kutney-Lee
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA.
| | - Dawn Smith
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Hilary Griffin
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Daniel Kinder
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joan Carpenter
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Joshua Thorpe
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of North Carolina- Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew Murray
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Scott Shreve
- Hospice and Palliative Care Program, Department of Veterans Affairs, Lebanon VA Medical Center, Lebanon, PA, USA
| | - Mary Ersek
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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Abstract
BACKGROUND Nearly 70% of nursing home residents are eligible for palliative care, yet few receive formal palliative care outside of hospice. Little is known about nursing home staff attitudes, knowledge, skills, and behaviors related to palliative care. METHODS We administered a modified survey measuring attitudes toward death to 146 nursing home staff members, including both clinical and nonclinical staff, from 14 nursing homes. RESULTS Nursing home staff generally reported feeling comfortable caring for the dying, but half believed the end of life is a time of great suffering. Pain control (63%), loneliness (52%), and depression (48%) were the most important issues identified with regard to these patients, and there was ambivalence about the use of strong pain medications and the utility of feeding tubes at the end of life. Top priorities identified for improving palliative care included greater family involvement (43%), education and training in pain control (50%) and in management of other symptoms (37%), and use of a palliative care team (35%) at their facility. CONCLUSIONS Findings show there is a need for more palliative care training and education, which should be built on current staff knowledge, skills, and attitudes toward palliative care.
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Leduc S, Cantor Z, Kelly P, Thiruganasambandamoorthy V, Wells G, Vaillancourt C. The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review. PREHOSP EMERG CARE 2020; 25:556-565. [PMID: 32644902 DOI: 10.1080/10903127.2020.1794084] [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] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Programs that seek to avoid emergency department (ED) visits from patients residing in long-term care facilities are increasing. We sought to identify existing programs where allied healthcare personnel are the primary providers of the intervention and, to evaluate their effectiveness and safety. METHODS We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. We reviewed 11,176 abstracts and included 22 studies in our narrative synthesis, which we grouped by intervention category. RESULTS We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Among studies measuring that outcome, 13/13 reported a decrease in ED visits, and 16/17 reported a decrease hospitalization in the intervention groups. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. CONCLUSION We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. However, most studies were observational and few assessed patient safety. Many identified programs focused on increased primary care for patients, and interventions addressing acute care issues, such as community paramedics, deserve more study.
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15
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Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113778. [PMID: 32466568 PMCID: PMC7312002 DOI: 10.3390/ijerph17113778] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 01/09/2023]
Abstract
Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.
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16
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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17
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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18
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Carpenter JG, Lam K, Ritter AZ, Ersek M. A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes. J Am Med Dir Assoc 2020; 21:583-596.e2. [PMID: 31924556 DOI: 10.1016/j.jamda.2019.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/11/2019] [Accepted: 11/20/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal. OBJECTIVE To examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care-symptom management, and ethical aspects-advance care planning). DESIGN Systematic review. METHODS We searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias. RESULTS We screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution. CONCLUSIONS AND IMPLICATIONS Heterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.
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Affiliation(s)
- Joan G Carpenter
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
| | - Karissa Lam
- University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Ashley Z Ritter
- University of Pennsylvania National Clinician Scholars Program, Philadelphia, PA
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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19
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Strautmann A, Allers K, Fassmer AM, Hoffmann F. Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey. BMC Palliat Care 2020; 19:2. [PMID: 31900141 PMCID: PMC6942381 DOI: 10.1186/s12904-019-0512-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.
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Affiliation(s)
- Anke Strautmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, D-26129, Oldenburg, Germany.
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | | | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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20
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Abstract
BACKGROUND End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Rieke Schnakenberg
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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21
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Pulst A, Fassmer AM, Schmiemann G. Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research. BMC Geriatr 2019; 19:155. [PMID: 31164101 PMCID: PMC6549333 DOI: 10.1186/s12877-019-1170-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents’ health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. Methods A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. Results After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident’s best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. Conclusion The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account. Electronic supplementary material The online version of this article (10.1186/s12877-019-1170-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany. .,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany.
| | - Alexander Maximilian Fassmer
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany.,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany
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22
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Andersson S, Årestedt K, Lindqvist O, Fürst CJ, Brännström M. Factors Associated With Symptom Relief in End-of-Life Care in Residential Care Homes: A National Register-Based Study. J Pain Symptom Manage 2018; 55:1304-1312. [PMID: 29305321 DOI: 10.1016/j.jpainsymman.2017.12.489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/13/2022]
Abstract
CONTEXT Residential care homes (RCHs) are a common place of death. Previous studies have reported a high prevalence of symptoms such as pain and shortness of breath among residents in the last week of life. OBJECTIVES The aim of the study was to explore the presence of symptoms and symptom relief and identify factors associated with symptom relief of pain, nausea, anxiety, and shortness of breath among RCH residents in end-of-life care. METHODS The data consisted of all expected deaths at RCHs registered in the Swedish Register of Palliative Care (N = 22,855). Univariate and multiple logistic regression analyses were conducted. RESULTS Pain was reported as the most frequent symptom of the four symptoms (68.8%) and the one that most often had been totally relieved (84.7%) by care professionals. Factors associated with relief from at least one symptom were gender; age; time in the RCH; use of a validated pain or symptom assessment scale; documented end-of-life discussions with physicians for both the residents and family members; consultations with other units; diseases other than cancer as cause of death; presence of ulcers; assessment of oral health; and prescribed pro re nata injections for pain, nausea, and anxiety. CONCLUSION Our results indicate that use of a validated pain assessment scale, assessment of oral health, and prescribed pro re nata injections for pain, nausea, and anxiety might offer a way to improve symptom relief. These clinical tools and medications should be implemented in the care of the dying in RCHs, and controlled trials should be undertaken to prove the effect.
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Affiliation(s)
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Kalmar County Hospital, Kalmar, Sweden
| | - Olav Lindqvist
- Department of Nursing, Umeå University, Umeå, Sweden; Department of Learning, Informatics, Management and Ethics/MMC, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Johan Fürst
- Department of Clinical Science, Faculty of Medicine, The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Margareta Brännström
- Department of Nursing, Umeå University, Campus Skellefteå, Umeå, Sweden; The Arctic Research Centre, Umeå University, Umeå, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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24
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Lima JC, Miller SC. Palliative Care Consults in U.S. Nursing Homes: Not Just for the Dying. J Palliat Med 2017; 21:188-193. [PMID: 28817348 DOI: 10.1089/jpm.2017.0099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Little is known about nursing home (NH) residents who receive palliative care (PC) consults in the United States. OBJECTIVE Separately by short versus long (≥90 days) stays, to describe NH residents with PC consults compared to a prevalent NH sample. DESIGN Descriptive longitudinal study. SETTING/SUBJECTS NH residents in 2008-2010 in 54 NHs. MEASUREMENTS Resident characteristics came from merged Medicare and NH data from the Centers for Medicare and Medicaid Services and consult information from two PC organizations that were the sole PC consult providers in the study NHs. RESULTS Four percent of all NH residents received a PC consult during the study period. Two-thirds had short NH stays, and 81% of short- and 27% of long-stay consult recipients were on the Medicare skilled nursing facility (SNF) benefit at the time of initial consult. Short- and long-stay NH residents with PC consults differed not only, in many respects, from NH residents generally but also from each other. Despite these differences, half of short-stay and 57% of long-stay residents were alive six months after initial consults. Residents dead at six months died at 33.5 and 34.5 median days (respectively) after initial consults. At six months, 65% of surviving short-stay consult recipients were in the community without hospice, while 59% of long-stay residents were in the NH without hospice or Medicare SNF care. CONCLUSION The high rates of SNF care and six-month survival among NH recipients of PC consults demonstrate the utility of these consults before Medicare hospice eligibility or use.
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Affiliation(s)
- Julie C Lima
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health , Providence, Rhode Island
| | - Susan C Miller
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health , Providence, Rhode Island
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Kada O, Janig H, Likar R, Cernic K, Pinter G. Reducing Avoidable Hospital Transfers From Nursing Homes in Austria: Project Outline and Baseline Results. Gerontol Geriatr Med 2017; 3:2333721417696671. [PMID: 28540338 PMCID: PMC5433662 DOI: 10.1177/2333721417696671] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 11/16/2016] [Accepted: 01/10/2017] [Indexed: 11/30/2022] Open
Abstract
Hospital transfers from nursing homes (NHs) are frequent, burdensome for residents, and often avoidable. The evidence regarding the effectiveness of interventions to reduce avoidable transfers is limited, and most projects focus on nurses’ knowledge and skills. In the present project, interventions focusing on nurses and physicians are integrated, elaborated, and implemented in 17 NHs. Results of the 6 months preintervention period are reported. Hospital transfer rates (N = 1,520) and basic data on all residents (N = 1,238) were collected prospectively. Nurses’ preintervention knowledge and self-efficacy were assessed using standardized questionnaires (N = 330). Many hospital transfers were initiated by nurses without physician involvement, polypharmacy was common, and a high potential for reducing transfers by increasing physician presence was observed. Nurses showed rather low knowledge but high self-efficacy. The results are discussed against the background of the interventions including enhancement of physician presence and geriatric quality circles.
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Affiliation(s)
- Olivia Kada
- Carinthia University of Applied Sciences, Feldkirchen, Austria
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[Palliative care in nursing homes : Results of a survey about knowledge and self-efficacy of nursing staff]. Schmerz 2017; 31:383-390. [PMID: 28078441 DOI: 10.1007/s00482-016-0184-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Nursing homes are confronted more and more with palliative care patients, which present a challenge for nursing and medical personnel. Deficits in the palliative care of geriatric patients have been repeatedly demonstrated and many nursing home residents, especially those suffering from dementia, are undersupplied regarding pain management. OBJECTIVES The present study was carried out to measure the knowledge and self-efficacy of nursing staff in the province of Carinthia (Austria) regarding palliative care of nursing home residents. MATERIAL AND METHODS A total of 330 nursing personnel were surveyed using the Bonn test for knowledge in palliative care (BPW), which measures knowledge and self-efficacy in nursing home personnel. In addition to descriptive analyses, the effects of the professional group (registered nurses vs. nursing assistants) and working experience were tested. RESULTS On average a little more than half of the knowledge items were answered correctly. Nurses' self-efficacy was high. Registered nurses exhibited more knowledge and higher self-efficacy compared to nursing assistants. Effects of working experience could only be demonstrated regarding self-efficacy. CONCLUSION The results are to a large extent in line with results from Germany and indicate the necessity of interventions for improving nurses' knowledge as a major basis for adequate palliative care in nursing home residents.
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