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Cohen-Mansfield J, Cohen R, Brill S. Awareness of Imminent Death: Results From a Mixed Methods Study of Israeli Family Caregivers' Perceptions of Their Awareness and That of the Patients for Whom They Cared. OMEGA-JOURNAL OF DEATH AND DYING 2024; 90:404-419. [PMID: 35695555 PMCID: PMC11440783 DOI: 10.1177/00302228221107236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We studied levels of awareness of impending death in older patients and their family caregivers. Using a mixed methods approach, we interviewed 70 family caregivers in Israel. Of the caregivers, 64% reported having been aware of the impending death, 33% were unaware, and 3% uncertain. Caregivers reported their perception that 36% of patients were aware, 27% unaware, and for 37% they were uncertain about the patient's awareness. Mechanisms that increased caregivers' awareness were specific diagnosis, significant deterioration in health, preparation by a health professional, or patient preparations for death. This study clarifies processes which aid awareness, and the relationship between awareness and actual preparation for dying.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Igor Orenstein Chair for the Study of Geriatrics, Tel Aviv University, Tel Aviv, Israel
- Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Rinat Cohen
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Shai Brill
- Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
- Beit Rivka Medical Center, Petah Tikva, Israel
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Ødbehr L, Hov R, Sanaker H, Jensen ÅS, Korup A, Sandsdalen T. Physicians' understandings and experience of advance care planning in Norwegian nursing homes: a qualitative study. BMC Palliat Care 2024; 23:158. [PMID: 38915021 PMCID: PMC11194902 DOI: 10.1186/s12904-024-01481-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/04/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Advance care planning is a way of facilitating conversations with patients about future health care, values, and preferences at end of life. Nursing home physicians have the medical responsibility and the main obligation to facilitate planned meetings with patients. Although there has been a great deal of focus on establishing advance care planning in Norwegian nursing homes, it has yet to be widely implemented. Stated reasons are that the work routines in a nursing home do not include such meetings or that implementation seems complex due to frail patients. The aim of this study is thus to explore how physicians understand and experience advance care planning and follow-up of care plans in Norwegian nursing homes. METHODS The study has a qualitative research design with a phenomenological-hermeneutic approach based on interviews of twelve nursing home physicians working in community care. Interviews were conducted in February 2023 to May 2023, using a semi-structured interview guide. All interviews were recorded on audio files, transcribed, and analyzed using structural text analysis. RESULTS The findings are presented based on the following themes: (1) advance care planning is a dialog and a process, (2) advance care planning implies clarifying mutual expectations, and (3) advance care planning that brings relief and hope to patients is a medical art. CONCLUSIONS Advance care planning is a complex and dynamic process that implies medical treatment, decisions on treatment level, pain relief, and formulation of care plans where the patient's self-determination and personal values are respected. It implies an ongoing dialogue between physicians, patients, and their relatives about values such as dignity, self-understanding, social relations, and existential questions at end of life. Advance care planning requires a holistic approach that meets patients' psychological and existential needs such as comfort, trust, hope, and respect as well as their preferences and concerns.
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Affiliation(s)
- Liv Ødbehr
- Department of Health and Nursing Sciences, Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Elverum, Norway.
| | - Reidun Hov
- Development Center for Nursing Homes and Home Services, Hamar Municipality, Hamar, Norway
| | - Harald Sanaker
- Municipal Medical Center, Ringsaker Municipality, Brumunddal, Norway
| | - Åsa Serholt Jensen
- Development Center for Nursing Homes and Home Services, Hamar Municipality, Hamar, Norway
| | - Aina Korup
- Municipal Medical Center, Ringsaker Municipality, Brumunddal, Norway
| | - Tuva Sandsdalen
- Department of Health and Nursing Sciences, Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
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Eklund Saksberg M, Bielsten T, Cahill S, Jaarsma T, Nedlund AC, Sandman L, Jaarsma P. Nurses' priority-setting for older nursing home residents during COVID-19. Nurs Ethics 2024:9697330241226597. [PMID: 38317371 DOI: 10.1177/09697330241226597] [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: 02/07/2024]
Abstract
BACKGROUND Ethical principles behind prioritization in healthcare are continuously relevant. However, applying ethical principles during times of increased need, such as during the COVID-19 pandemic, is challenging. Also, little is known about nursing home nurses' prioritizations in their work to achieve well-being and health for nursing home residents. AIM The aim of this study was to explore nursing home nurses' priority-setting for older nursing home residents in Sweden during the COVID-19 pandemic. RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT We conducted a qualitative interview study. Data were collected through in-depth interviews (retrospective self-reports) between February and May 2021 with 21 nursing home nurses. To help respondents to recall their memories, we used the critical incident technique (CIT). We analyzed data within the theoretical framework and the methodological orientation of content analysis. ETHICAL CONSIDERATIONS Written and verbal consent was obtained before the interviews, and information was given to participants informing them that participation was entirely voluntary. The Swedish Ethical Review Agency gave an advisory opinion stating that there were no ethical objections to the research project (Dnr. 2020-05649). FINDINGS We identified an overarching theme-nursing home nurses struggling on multiple fronts, "just do it"-and seven categories: striving for survival and caring about a dignified death; responding sensitively to relatives' expectations; ranking the urgency of needed care; responding to input from different actors; combating the spread of infection in unconventional ways; taking the lead and doing what is required; and following the ideals of person-centered nursing. CONCLUSIONS Nurses' priority-setting for older nursing homes residents during the COVID-19 pandemic meant strain and struggle. In some cases, nurses had taken responsibility for priorities falling outside their statutory powers. Different demands and interests affected nurses' priorities. Nursing home nurses need organizational and managerial support to prioritize.
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Che SL, Leong SM, Lau WS, Tam KI. Reliability and Validation Study of Advance Care Planning Practice Scale among Health and Social Care Professionals. Healthcare (Basel) 2024; 12:200. [PMID: 38255087 PMCID: PMC10815370 DOI: 10.3390/healthcare12020200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/31/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
Advance care planning (ACP) is a crucial process in clinical practice, enabling individuals to articulate their care preferences and goals, with significant implications for future healthcare. However, ACP practice of health and social care professionals (HSCPs) concerning patients, or their family members are rarely explored. The objective of the study was to adapt and validate a four-item scale assessing ACP practices of HSCPs toward patients or their family members. The ACP Practice Scale was evaluated through a cross-sectional online survey administered to HSCPs in Macao, assessing its factor structure, validity, and reliability. Based on a sample of 186 valid responses, the ACP Practice Scale demonstrated satisfactory levels of validity and reliability among HSPCs in Macao. The four-item scale explained 65.87% of the variance in ACP practice and exhibited strong internal consistency, with Cronbach's alpha and McDonald's omega coefficients of 0.82. Furthermore, item factor loadings ranged from 0.71 to 0.90. The ACP Practice Scale provides reliable and valid measurements of ACP practice among HSCPs. This instrument can help to enhance our understanding of ACP practices in clinical settings and support the advancement of advance care planning.
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Affiliation(s)
- Sok-Leng Che
- Nursing and Health Education Research Centre, Kiang Wu Nursing College of Macau, Macao SAR, China;
| | - Sok-Man Leong
- Education Department, Kiang Wu Nursing College of Macau, Macao SAR, China;
| | - Wing-Sze Lau
- Lar de Cuidados de Ká Hó da Federação das Associações dos Operários de Macau, Estr. de Nossa Sra. de Ka Ho, Macao SAR, China
| | - Kuai-In Tam
- Education Department, Kiang Wu Nursing College of Macau, Macao SAR, China;
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Plez L, Holland M, Kulasegarampillai P, Sieu TC, Blain-Moraes S. "I made you a small room in my heart": how therapeutic clowns meet the needs of older adults in nursing homes. Int J Qual Stud Health Well-being 2023; 18:2238989. [PMID: 37499136 PMCID: PMC10375930 DOI: 10.1080/17482631.2023.2238989] [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] [Received: 12/07/2022] [Accepted: 07/17/2023] [Indexed: 07/29/2023] Open
Abstract
Therapeutic clowns are increasingly common in nursing homes, where residents often encounter factors that can undermine their quality of life and dignity. We aimed to understand the strategies of successful therapeutic clowning with a diverse older adult population, and the unique contributions of elder-clowning to the nursing home experience. Using an interpretivist descriptive methodology, twenty-three (n=23) experienced therapeutic clowns from eight countries were interviewed to understand the needs of nursing home residents met by elder-clowns, and strategies and techniques the clowns use to address them. Participants identified five major needs: to escape routine; for reassurance of worth; for meaningful, personalized social interaction unrestricted by communication barriers; to have culturally meaningful opportunities for reminiscence; and to have a space where residents could be unapologetically themselves. The artistic and emotional strategies used by the therapeutic clowns to address these needs illustrate how creativity, imagination and relational presence can provide nursing home residents with a sense of being known and belonging. Elder-clowns also positively affect the nursing home staff and enrich the interpersonal interactions in the residence. Through their focus on the social and emotional needs of residents, elder-clowns can play an important and distinct role in creating an optimal nursing home experience.
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Affiliation(s)
- Ludivine Plez
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | | | | | - Thun-Carl Sieu
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
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Hatzikiriakidis K, Ayton D, Skouteris H, Patitsas L, Smith K, Dhulia A, Poon P. A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care. Palliat Med 2023; 37:1079-1099. [PMID: 37448148 DOI: 10.1177/02692163231183007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted. AIM The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care. DESIGN A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews. DATA SOURCES Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care. RESULTS A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature. CONCLUSIONS This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.
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Affiliation(s)
- Kostas Hatzikiriakidis
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton VIC, Australia
| | - Darshini Ayton
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton VIC, Australia
| | - Helen Skouteris
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton VIC, Australia
- Warwick Business School, University of Warwick, Coventry, West Midlands, United Kingdom
| | - Luke Patitsas
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton VIC, Australia
| | | | | | - Peter Poon
- Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Maehre KS, Bergdahl E, Hemberg J. Patients', relatives' and nurses' experiences of palliative care on an advanced care ward in a nursing home setting in Norway. Nurs Open 2023; 10:2464-2476. [PMID: 36451339 PMCID: PMC10006603 DOI: 10.1002/nop2.1503] [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: 05/12/2022] [Revised: 09/08/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022] Open
Abstract
PATIENT OR PUBLIC CONTRIBUTION Patients, relatives and nurses were involved in this study. AIM The aim was to explore patients', relatives' and nurses' experiences of palliative care on an advanced care ward in a nursing home setting after implementation of the Coordination Reform in Norway. DESIGN Secondary analysis of qualitative interviews. METHODS Data from interviews with 19 participants in a nursing home setting: severely ill older patients in palliative care, relatives and nurses. Data triangulation influenced by Miles and Huberman was used. RESULTS The overall theme was "Being in an unfamiliar and uncaring culture leaves end-of-life patients in desperate need of holistic, person-centred and co-creative care". The main themes were: "Desire for engaging palliative care in a hopeless and lonely situation", "Patients seeking understanding of end-of-life care in an unfamiliar setting" and "Absence of sufficient palliative care and competence creates insecurity". The patients and relatives included in this study experienced an uncaring culture, limited resources and a lack of palliative care competence, which is in direct contrast to that which is delineated in directives, guidelines and recommendations. Our findings reveal the need for policymakers to be more aware of the challenges that may arise when healthcare reforms are implemented. Future research on palliative care should include patients', relatives' and nurses' perspectives.
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Affiliation(s)
- Kjersti Sunde Maehre
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Elisabeth Bergdahl
- School of Health Sciences, Institution of Health Sciences, Örebro University, Örebro, Sweden
| | - Jessica Hemberg
- Department of Caring Sciences, Faculty of Education and Welfare Studies, Åbo Akademi University, Vaasa, Finland
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Hartviksen TA, Aspfors J, Uhrenfeldt L. Dignity at stake - relatives' experiences of influencing dignified care in nursing homes. BMC Health Serv Res 2023; 23:194. [PMID: 36823580 PMCID: PMC9949906 DOI: 10.1186/s12913-023-09175-3] [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: 10/05/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Dignity, in the care of older nursing home residents, has been an increasingly part of the public discourse the recent years. Despite a growing body of knowledge about dignity and indignity in nursing homes, we have less knowledge of how relatives experience their role in this context. This study is a follow-up to a previous study in nursing homes, which gave rise to concern about the relatives' descriptions of residents' dignity. The aim of this current study is to critically discuss relatives' experiences of influencing the dignified care of residents of nursing homes. METHODS Methodologically, the study is informed by a critical hermeneutic stance, where the analysis is guided by a qualitative interpretive approach and a humanizing framework. This is a secondary analysis that includes data from five semi-structured focus groups from a previous study. The participants were 18 relatives of 16 residents living in two nursing homes in rural northern Norway. RESULTS The main theme in this study, preventing missed care when dignity is at stake, is identified when relatives of nursing homes experience that they are able to influence dignified care by (a) pinpointing to prevent missed care and (b) compensating when dignity is threatened. CONCLUSIONS Despite their stated good intentions to safeguard dignity, relatives of nursing homes experience being alienated in their attempts to change what they describe as undignified and unacceptable practice into dignified care. The relatives' observations of dignity and indignity are, contrary to what national and international regulations require, not mapped and/or used in any form of systematic quality improvement work. This indicates that knowledge-based practice in nursing homes, including the active application of user and relative knowledge, has untapped potential to contribute to quality improvement towards dignified care.
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Affiliation(s)
| | - Jessica Aspfors
- grid.465487.cFaculty of Education and Arts, Nord University, Bodø, Norway
| | - Lisbeth Uhrenfeldt
- grid.465487.cFaculty of Nursing and Health Sciences, Nord University, Bodø, Norway
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Sopcheck J, Tappen RM. Nursing Home Resident, Family, and Staff Perspectives on Hospital Transfers for End-of-Life Care. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:1046-1068. [PMID: 33632028 DOI: 10.1177/0030222821997708] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Residents who are terminally ill often experience transfers to the emergency department resulting in hospitalizations, which may be potentially avoidable with treatment in the nursing home. This qualitative study explored the perspectives of 15 residents, 10 family members, and 20 nursing home staff regarding end-of-life care and the circumstances prompting resident transfers. Data analysis of participant interviews conducted January to May 2019 in a South Florida nursing home identified four themes related to transfer to the hospital: time left to live, when aggressive treatments would be unavailing, not knowing what the nursing home can do, and transfer decisions are situation-dependent. Study findings underscore the importance of increasing resident and family awareness of treatments available in the nursing home and person-centered advance care planning discussions. Further research should explore the reasons for residents' and family members' choice of aggressive therapies and their goals for care at the end of life.
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Affiliation(s)
- Janet Sopcheck
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, United States
| | - Ruth M Tappen
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, United States
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Gonella S, Conti A, Albanesi B, Antal A, Dimonte V, Di Giulio P. Lived experiences of end-of-life communication among nursing home staff: An interpretive phenomenological study. J Adv Nurs 2023; 79:698-710. [PMID: 36447384 DOI: 10.1111/jan.15489] [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: 05/02/2022] [Revised: 09/16/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
AIMS To explore and understand lived experiences of end-of-life communication among nursing home staff. DESIGN Interpretive phenomenological study. METHODS In-person, semi-structured, in-depth interviews were conducted from May to August 2021 with 21 nursing home staff members involved in end-of-life communication (four managers, four chief nurses, three chief medical officers, three nurses, three psychologists, two occupational therapists, one chief nurse aide and one nurse aide). Data were analysed by van Manen's hermeneutic approach, which uses the lifeworld existentials of spatiality, corporeality, temporality and relationality to guide reflection on the human experience. Data were reported according to the Consolidated Criteria for Reporting Qualitative Research. RESULTS Thirteen categories were identified and framed within the four existentials. Regarding spatiality, end-of-life communication took place in a physical, mental, socio-cultural and professional competence space. With regard to corporeality, interviewees reported difficulties in managing their own feelings and those of family caregivers. For temporality, interviewees reported delays in end-of-life communication due to staffing issues and an increase in urgent and temporary relief admissions to nursing homes. To compensate, they tried to assure that all interactions that did take place were of high quality. Finally, with regard to relationality, interviewees lived end-of-life communication through their relationships with family caregivers and colleagues. The supportive role of colleagues was expressed as teamwork, which helped promote reflexivity about how to tailor communication, manage challenging emotions and situations, set aside time for communication, and prepare family caregivers for death. CONCLUSION End-of-life communication was an all-encompassing experience for nursing home staff. The supportive role of colleagues was stressed across all existentials, suggesting that teamwork is essential in delivering effective communication at the end-of-life. PATIENT OR PUBLIC CONTRIBUTION There was no patient or public contribution to this study, which addresses the experiences of nursing home staff only.
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Affiliation(s)
- Silvia Gonella
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy.,Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessio Conti
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Beatrice Albanesi
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Alexandra Antal
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy.,Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
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Yildiz B, Korfage IJ, Witkamp EF, Goossensen A, van Lent LG, Pasman HR, Onwuteaka-Philipsen BD, Zee M, van der Heide A. Dying in times of COVID-19: Experiences in different care settings - An online questionnaire study among bereaved relatives (the CO-LIVE study). Palliat Med 2022; 36:751-761. [PMID: 35264024 PMCID: PMC9006387 DOI: 10.1177/02692163221079698] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The COVID-19 pandemic and restricting measures have affected end-of-life care across different settings. AIM To compare experiences of bereaved relatives with end-of-life care for a family member or friend who died at home, in a hospital, nursing home or hospice during the pandemic. DESIGN An open observational online survey was developed and disseminated via social media and public fora (March-July 2020). Data were analyzed using descriptive statistics and logistic regression analyses. PARTICIPANTS Individuals who lost a family member or friend in the Netherlands during the COVID-19 pandemic. RESULTS The questionnaire was filled out by 393 bereaved relatives who lost a family member or friend at home (n = 68), in a hospital (n = 114), nursing home (n = 176) or hospice (n = 35). Bereaved relatives of patients who died in a hospital most often evaluated medical care (79%) as sufficient, whereas medical care (54.5%) was least often evaluated as sufficient in nursing homes. Emotional support for relatives was most often evaluated as sufficient at home (67.7%) and least often in nursing homes (40.3%). Sufficient emotional support for relatives was associated with a higher likelihood to rate the place of death as appropriate. Bereaved relatives of patients who died at a place other than home and whose care was restricted due to COVID-19 were less likely to evaluate the place of death as appropriate. CONCLUSION End-of-life care during the COVID-19 pandemic was evaluated least favourably in nursing homes. The quality of emotional support for relatives and whether care was restricted or not were important for assessing the place of death as appropriate.
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Affiliation(s)
- Berivan Yildiz
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ida J Korfage
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erica Fe Witkamp
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Research Centre Innovations in Care, University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Liza Gg van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - H Roeline Pasman
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Masha Zee
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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Kastbom L, Falk M, Karlsson M, Tengblad A, Milberg A. Prevalence, content and significance of advance care planning in nursing home patients. Scand J Prim Health Care 2022; 40:29-38. [PMID: 35170393 PMCID: PMC9090430 DOI: 10.1080/02813432.2022.2036429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Studies on advance care planning in nursing homes are rare, and despite their demonstrated favourable effects on end-of-life care, advance care plans are often lacking. Therefore, we wished to explore: (i) the prevalence of advance care plans in a Swedish nursing home setting using two different definitions, (ii) the content of advance care plans, (iii) adherence to the content of care plans and (iv) possible associations between the presence of advance care planning and background characteristics, physician attendance and end-of-life care. DESIGN Retrospective chart review. SETTING Twenty-two nursing homes in Sweden. SUBJECTS A total of 367 deceased patients (included between 1 June 2018 and 23 May 2020) who had lived in nursing homes. MAIN OUTCOME MEASURES Electronic health record data on the prevalence of advance care plans with two different definitions and variables regarding background characteristics, physician attendance and end-of-life care, were collected. RESULTS Of the study population, 97% had a limited care plan (ACP I) documented. When using the comprehensive definition (ACP II), also including patient's preferences and involvement of family members in advance care planning, the prevalence was 77%. Patients with dementia more often had care plans, and a higher physician attendance was associated with presence of advance care plans. Prescription of palliative drugs and information to family members of the patient's deterioration and impending death were more common in patients with care plans compared to those where such plans were missing. There was adherence to the care plan content. CONCLUSION In contrast to previous research, this study showed a high prevalence of advance care plans in nursing home patients. Patients with care plans more frequently received prescriptions of palliative drugs and their family members were informed to a greater extent about the patient's deterioration and impending death compared to those without care plans. These aspects are often seen as vital components of good palliative care.Key pointsStudies on advance care planning in nursing homes are rare, and despite their demonstrated positive effects on end-of-life care, advance care plans are often lacking.The present study revealed a high prevalence of advance care plans (77-97% depending on definition) in nursing home patients.Patients with dementia more often had advance care plans, and a higher physician attendance was associated with presence of care plans.Advance care plans were positively associated with components of good palliative care, such as prescriptions of palliative drugs and information to family.
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Affiliation(s)
- Lisa Kastbom
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Primary Health Care Centre in Kisa, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- CONTACT Lisa Kastbom Department of Health, Medicine and Caring Sciences, Linköping University, pl 14, LinköpingS-581 83, Sweden
| | - Magnus Falk
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Primary Health Care Centre in Kärna, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marit Karlsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Advanced Home Care in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Tengblad
- Primary Health Care Centre in Wetterhälsan, Jönköping, Sweden
| | - Anna Milberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Advanced Home Care in Norrköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Gonella S, Mitchell G, Bavelaar L, Conti A, Vanalli M, Basso I, Cornally N. Interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes: A mixed-methods systematic review. Palliat Med 2022; 36:268-291. [PMID: 34965759 DOI: 10.1177/02692163211066733] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Most people with dementia transition into nursing homes as their disease progresses. Their family caregivers often continue to be involved in their relative's care and experience high level of strain at the end of life. AIM To gather and synthesize information on interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes and provide a set of recommendations for practice. DESIGN Mixed-Methods Systematic Review (PROSPERO no. CRD42020217854) with convergent integrated approach. DATA SOURCES Five electronic databases were searched from inception in November 2020. Published qualitative, quantitative, and mixed-method studies of interventions to support family caregivers of people with advanced dementia at the end of life in nursing home were included. No language or temporal limits were applied. RESULTS In all, 11 studies met the inclusion criteria. Data synthesis resulted in three integrated findings: (i) healthcare professionals should engage family caregivers in ongoing dialog and provide adequate time and space for sensitive discussions; (ii) end-of-life discussions should be face-to-face and supported by written information whose timing of supply may vary according to family caregivers' preferences and the organizational policies and cultural context; and (iii) family caregivers should be provided structured psychoeducational programs tailored to their specific needs and/or regular family meetings about dementia care at the end of life. CONCLUSION The findings provide useful information on which interventions may benefit family caregivers of people with advanced dementia at the end of life and where, when, and how they should be provided.
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Affiliation(s)
- Silvia Gonella
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy.,Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gary Mitchell
- School of Nursing & Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, Northern Ireland
| | - Laura Bavelaar
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Alessio Conti
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Mariangela Vanalli
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Roma, Italy
| | - Ines Basso
- School of Nursing, Azienda Ospedaliera "SS Antonio e Biagio e Cesare Arrigo," Alessandria, Italy
| | - Nicola Cornally
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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Meshkovska B, Scheller DA, Wendt J, Jilani H, Scheidmeir M, Stratil JM, Lien N. Barriers and facilitators to implementation of direct fruit and vegetables provision interventions in kindergartens and schools: a qualitative systematic review applying the consolidated framework for implementation research (CFIR). Int J Behav Nutr Phys Act 2022; 19:11. [PMID: 35101084 PMCID: PMC8805256 DOI: 10.1186/s12966-022-01246-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although children's intake of fruit and vegetables has seen a recent rise, almost half of adolescents do not eat even one piece of fruit or vegetables per day. One way to address this problem is through interventions that provide fruit and vegetables directly to children in kindergartens and schools. For such interventions to meet their intended goals, what is important to consider in addition to impact is implementation. Our objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the Consolidated Framework for Implementation Research (CFIR). METHODS A systematic search was designed and run in November 2019 for: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials. A keyword search of the journal Implementation Science was completed. Screening of titles and abstracts (n = 5427) and full texts (n = 227), led to 14 included articles. Coding and analysis were done using the framework method and CFIR. RESULTS The following CFIR constructs were found relevant: 1) intervention characteristics domain: 'design quality and packaging', 'adaptability' 'cost'; 2) outer setting: 'cosmopolitanism', 'external policy and incentives' 'patients' needs and resources'; 3) inner setting: 'implementation climate', 'readiness for implementation' and 'structural characteristics'; 4) characteristics of individuals: 'individual stage of change', 'knowledge and beliefs about the intervention' 5) process: 'engaging', 'executing' and 'reflecting and evaluating'. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts. CONCLUSIONS CFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Revisions are encouraged to allow adequate space for perceptions of various implementation actors and the target group. PROSPERO REGISTRATION CRD42020167697.
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Affiliation(s)
| | - Daniel A. Scheller
- Division of Sports and Rehabilitation, Department of Internal Medicine II, Ulm University Medical Centre, Ulm, Germany
| | - Janine Wendt
- Division of Sports and Rehabilitation, Department of Internal Medicine II, Ulm University Medical Centre, Ulm, Germany
| | - Hannah Jilani
- Institute of Public Health and Nursing Research - IPP, University of Bremen and Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Marie Scheidmeir
- Department of Psychology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jan M. Stratil
- Institute for Medical Information Processing, Biometry, and Epidemiology – IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
| | - Nanna Lien
- Department of Nutrition, University of Oslo, Oslo, Norway
| | - on behalf of the PEN Consortium
- Department of Nutrition, University of Oslo, Oslo, Norway
- Division of Sports and Rehabilitation, Department of Internal Medicine II, Ulm University Medical Centre, Ulm, Germany
- Institute of Public Health and Nursing Research - IPP, University of Bremen and Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
- Department of Psychology, Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology – IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
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15
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Fernández-Rodríguez Á, Sarabia-Cobo C, Molina-Mula J. Knowledge and attitudes towards living wills among healthcare professionals, residents and relatives in nursing homes: A qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e245-e254. [PMID: 34028118 DOI: 10.1111/hsc.13434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 04/08/2021] [Accepted: 04/28/2021] [Indexed: 02/05/2023]
Abstract
Living wills are a tool to support the principle of autonomy in end-of-life situations, when the person does not have the capacity to make decisions. The aim was to explore the knowledge and attitudes of residents, relatives and healthcare professionals in nursing homes in Cantabria regarding living wills. A qualitative phenomenological design was conducted. Two focus groups were held with seven participants in each group. A sample of 14 people participated in this study: four residents, five relatives and five professionals. This study was approved by the Clinical Research Ethics Committee of Cantabria. Two main categories were found, with six subcategories each: death, with six subcategories-as a social taboo, as a natural process, facing death, accompanying uncertainties, unnecessary lengthening of life and guilt-and living wills, with six subcategories-knowledge, unknowingness or misconceptions, usefulness, strategies to promote dissemination, intention of granting a living will and the professional's role in restricting or promoting autonomy. Unknowingness or misconceptions and uncertainties in relation to death were the most represented subcategories of each category. Although the attitudes among the study participants were mostly positive, there is a lack of knowledge concerning living wills, which is enhanced by the social taboo related to death.
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Affiliation(s)
| | - Carmen Sarabia-Cobo
- Faculty of Nursing, University of Cantabria, IDIVAL Nursing Research Group, Santander, Spain
| | - Jesús Molina-Mula
- Department of Nursing and Physiotherapy, University of the Balearic Islands, Mallorca, Spain
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16
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Sopcheck J, Tappen RM. Communicating With Nursing Home Residents About End of Life. Am J Hosp Palliat Care 2021; 39:1257-1265. [PMID: 34967673 DOI: 10.1177/10499091211064835] [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: 11/17/2022] Open
Abstract
Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.
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Affiliation(s)
| | - Ruth M Tappen
- 1782Florida Atlantic University, Boca Raton, FL, USA
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17
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The relationship between caregivers' perceptions of end-of-life care in long-term care and a good resident death. Palliat Support Care 2021; 18:683-690. [PMID: 32410716 DOI: 10.1017/s1478951520000292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Quality end-of-life (EOL) care is critical for dying residents and their family/friend caregivers. While best practices to support resident comfort at EOL in long-term care (LTC) homes are emerging, research rarely explores if and how the type of care received at EOL may contribute to caregivers' perceptions of a good death. To address this gap, this study explored how care practices at EOL contributed to caregivers' perceptions of a good resident death. METHOD This study used a retrospective cross-sectional survey design. Seventy-eight participants whose relative or friend died in one of five LTC homes in Canada completed self-administered questionnaires on their perceptions of EOL care and perceptions of a good resident death. RESULTS Overall, caregivers reported positive experiences with EOL care and perceived residents to have died a good death. However, communication regarding what to expect in the final days of life and attention to spiritual issues were often missing components of care. Further, when explored alongside direct resident care, family support, and rooming conditions, staff communication was the only aspect of EOL care significantly associated with caregivers' perceptions of a good resident death. SIGNIFICANCE OF RESULTS The findings of this study suggest that the critical role staff in LTC play in supporting caregivers' perceptions of a good resident death. By keeping caregivers informed about expectations at the very end of life, staff can enhance caregivers' perceptions of a good resident death. Further, by addressing spiritual issues staff may improve caregivers' perceptions that residents were at peace when they died.
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18
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Sævareid TJL, Pedersen R, Magelssen M. Positive attitudes to advance care planning - a Norwegian general population survey. BMC Health Serv Res 2021; 21:762. [PMID: 34334131 PMCID: PMC8327435 DOI: 10.1186/s12913-021-06773-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning. Methods An electronic survey to a nationally representative web panel of Norwegian adults. Results From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness. Conclusions Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.
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Affiliation(s)
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
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19
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Hjorth NE, Schaufel MA, Sigurdardottir KR, Haugen DRF. Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study. BMJ Open Respir Res 2021; 7:7/1/e000485. [PMID: 32107203 PMCID: PMC7047484 DOI: 10.1136/bmjresp-2019-000485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND AIMS Advance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014-2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP. METHODS Conversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient's medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation. RESULTS Fifty-one patients participated in ACP conversations (41-86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice. CONCLUSIONS Patients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.
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Affiliation(s)
- Nina Elisabeth Hjorth
- Department of Anaesthesia and Surgical Services, Specialist Palliative Care Team, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Margrethe Aase Schaufel
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Katrin Ruth Sigurdardottir
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.,Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Dagny R Faksvåg Haugen
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
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20
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Laging BL, Nay R, Bauer M, Laging R, Walker K, Kenny A. Advance care planning practices in the nursing home setting: A secondary analysis. THE GERONTOLOGIST 2021; 61:1307-1316. [PMID: 33624074 DOI: 10.1093/geront/gnab028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Advance care planning is intended to support resident's preferences regarding health decisions, even when they can no longer participate. Little is known about the power discourses influencing how residents, family-members, and healthcare workers engage in advance care planning and how advance care directives are used if conflict arises. A large critical ethnographic study was conducted exploring decision making when a resident's health deteriorates in the nursing home setting. Advance care planning practices were not the focus of the original study, but the richness of the data warranted further exploration. A new research question was developed to inform a secondary analysis: How does advance care planning influence the relationship between resident values and clinical expertise when determining a direction of care at the time of a resident deterioration? RESEARCH DESIGN AND METHODS A secondary analysis of data from an ethnographic study involving 184 hours of participatory observation, 40 semi-structured interviews and advance care planning policies and document review undertaken in in two nursing homes in Melbourne, Australia. RESULTS Advance care planning may result in inaccurate documentation of residents' preferences and devalue clinical decision-making and communication with residents and family-members at the time of deterioration. DISCUSSION AND IMPLICATIONS Advance care planning may contribute towards a reductionist approach to decision-making. There is an urgent need for the development of evidence-based policy and legislation to support residents, families, and healthcare workers to make appropriate decisions, including withholding invasive treatment when a resident deteriorates.
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Affiliation(s)
- Bridget L Laging
- Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
| | - Rhonda Nay
- School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria Australia
| | - Rohan Laging
- Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Katie Walker
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amanda Kenny
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
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21
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Overview of the Motivation of Advance Care Planning: A Study from a Medical Center in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020417. [PMID: 33430302 PMCID: PMC7825806 DOI: 10.3390/ijerph18020417] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/25/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
(1) Background: Since Taiwan's Patient Right to Autonomy Act took effect in 2019, up to ten thousand declarants have participated in advance care planning (ACP) and have signed advance directives (ADs). Relative to the entire population of Taiwan, only a small percentage have completed ACP. This study sought to understand the motivations of Taiwanese who have participated in ACP, so as to increase the percentage of individuals participating in ACP and signing ADs; (2) Objectives: To understand the motivations that drive Taiwanese individuals to participate in ACP discussions.; (3) Methods: A retrospective secondary data analysis was performed in this study. The participants consisted of declarants who completed their ACP at a medical center in Taiwan in 2019; (4) Results: During the study period, 946 individuals completed their ACP. Of those declarants, 66.7% were over 60 years of age; 66.5% completed the process in groups of three or more; 49.5% completed their ACP free of charge; and 35 declarants had designated a health care agent (HCA). The declarants' four main motivations for participating in ACP were "looking forward to dying with dignity," "making end-of-life preparations," "fear of being a social and economic burden on family members," and "reluctance to let family members take on the responsibility of making decisions." Furthermore, statistically significant differences were observed between the declarants in terms of gender, age, designation of an HCA, and motivations for participating in ACP. Females, declarants aged below 60 years, and declarants with a designated HCA tended to participate in ACP due to "reluctance to let family members to take on the responsibility of making decisions". Males, declarants aged above 60 years, and declarants without an HCA came for ACP because of "fear of being a social and economic burden on family members". (5) Conclusions: The main motivations of Taiwanese individuals who sought ACP were to die with dignity and to have an early understanding of end-of-life treatment and care models. Secondly, these individuals hoped that their families would not have to take on the responsibility of making decisions. They also did not want to impact their families socially and economically. In this regard, providing economic subsidies might enhance the Taiwanese public's intentions to seek ACP discussions on their own initiative.
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22
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Ye P, Fry L, Champion JD. Changes in Advance Care Planning for Nursing Home Residents During the COVID-19 Pandemic. J Am Med Dir Assoc 2021; 22:209-214. [PMID: 33290730 PMCID: PMC7674113 DOI: 10.1016/j.jamda.2020.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Describe the care preference changes among nursing home residents receiving proactive Advance Care Planning (ACP) conversations from health care practitioners during the COVID-19 pandemic. DESIGN Retrospective chart review. SETTING AND PARTICIPANTS Nursing home residents (n = 963) or their surrogate decision makers had at least 1 ACP conversation with a primary health care practitioner between April 1, 2020, and May 30, 2020, and made decisions of any changes in code status and hospitalization preferences. METHODS Health care practitioners conducted ACP conversations proactively with residents or their surrogate decision makers at 15 nursing homes in a metropolitan area of the southwestern United States between April 1, 2020, and May 30, 2020. ACP conversations reviewed code status and goals of care including Do Not Hospitalize (DNH) care preference. Resident age, gender, code status, and DNH choice before and after the ACP conversations were documented. Descriptive data analyses identified significant changes in resident care preferences before and after ACP conversations. RESULTS Before the most recent ACP discussion, 361 residents were full code status and the rest were Out of Hospital Do Not Resuscitate (DNR). Of the individuals with Out of Hospital DNR, 188 residents also chose DNH. After the ACP conversation, 88 residents opted to change from full code status to Out of Hospital DNR, thereby increasing the percentage of residents with Out of Hospital DNR from 63% to 72%. Almost half of the residents decided to keep or change to the DNH care option after the ACP conversation. CONCLUSION AND IMPLICATIONS Proactive ACP conversations during COVID-19 increased DNH from less than a quarter to almost half among the nursing home residents. Out of Hospital DNR increased by 9%. It is important for all health care practitioners to proactively review ACP with nursing home residents and their surrogate decision makers during a pandemic, thereby ensuring care consistent with personal goals of care and avoiding unnecessary hospitalizations.
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Affiliation(s)
- Ping Ye
- The School of Nursing, the University of Texas at Austin, Austin, TX, USA; Austin Geriatric Specialists, Austin, TX, USA.
| | - Liam Fry
- Austin Geriatric Specialists, Austin, TX, USA; Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Cipolletta S, Reggiani M. End-of-life care after the legal introduction of advance directives: A qualitative study involving healthcare professionals and family caregivers of patients with amyotrophic lateral sclerosis. Palliat Med 2021; 35:209-218. [PMID: 33112196 DOI: 10.1177/0269216320967280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advance care planning and advance directives play a key role in the care of life-threatening illnesses such as amyotrophic lateral sclerosis. AIM The aim of the present study is to explore how the introduction of these features by law improves the experience of end-of-life care. DESIGN Five focus groups were conducted in Italy 1 year after the new law on advance directives was introduced. SETTING/PARTICIPANTS Purposive sampling was used to recruit 24 health professionals and 23 family caregivers of patients with amyotrophic lateral sclerosis, for a total of 47 participants. RESULTS The thematic analysis, conducted through the use of ATLAS.ti software, identified four thematic areas: best practices, managing difficulties, care relationships and proposals. The results indicated a lack of organization, collaboration and continuity on the part of healthcare services and professionals, a lack of information on palliative care, advance care planning, and advance directives. End-of-life care is often left to the good will of the individual professional. Difficulties can also derive from ethical dilemmas concerning end-of-life decision-making and from a lack of communication and relationships between health professionals, patients and their families. CONCLUSION The introduction of advance directives by law has not been sufficient to improve end-of-life care. In order to make legal regulation effective, the organization of healthcare services needs to be improved and clearer procedures have to be implemented and shared with patients and families.
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24
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Saevareid TJL, Pedersen R, Thoresen L. Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study. J Adv Nurs 2020; 77:879-888. [PMID: 33230934 DOI: 10.1111/jan.14661] [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: 01/27/2020] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 01/23/2023]
Abstract
AIMS To describe advance care planning in nursing homes when residents with cognitive impairment and/or their next of kin participated and identify associated challenges. DESIGN A qualitative study of nine advance care planning conversations in four Norwegian nursing home wards. During the implementation of advance care planning, we purposively sampled residents with cognitive impairment, their next of kin and healthcare personnel. The implementation followed a "whole-ward" approach aimed at involving the whole ward in fostering an inclusive, holistic advance care planning discussion. Involving as many residents as possible, preferably together with their next of kin, were central. METHODS From observed and audio-recorded advance care planning conversations that took place from November 2015 to June 2016, we conducted a thematic analysis of the transcripts and field notes. Reporting adhered to the COREQ guidelines. RESULTS Residents actively relayed their preferences regarding healthcare and end-of-life issues, despite the cognitive impairment. Next of kin provided constructive support and conversations were largely resident-focused. However, involving residents was also challenging, findings included: residents' preferences were often vague, relevant medical information from healthcare personnel lacked and the next of kin were sometimes unaware of the resident's previously held preferences. Moreover, residents tended to focus more on the past and present than the future end-of-life care. CONCLUSIONS Residents with cognitive impairment can participate actively and meaningfully in advance care planning, if the healthcare personnel actively listens. However, several challenges can arise. Supported decision-making can improve communication and resident involvement, reinforcing a relational understanding of autonomy. IMPACT Persons with cognitive impairment should be invited to participate in advance care planning. Their participation may make its benefits and more person-centred care attainable to persons that are often not involved. Successful involvement of persons with cognitive impairment in advance care planning may rely on robust implementation.
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Affiliation(s)
| | | | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
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25
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What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences. Palliat Support Care 2020; 19:208-216. [PMID: 32830632 DOI: 10.1017/s1478951520000747] [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: 11/07/2022]
Abstract
OBJECTIVES Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs. METHODS This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes. RESULTS FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care. SIGNIFICANCE OF RESULTS Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.
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Frey R, Barham S, Balmer D, Boyd M, Robinson J, Gott M. Palliative care delivery in residential aged care: bereaved family member experiences of the Supportive Hospice Aged Residential Exchange (SHARE) intervention. BMC Palliat Care 2020; 19:127. [PMID: 32807170 PMCID: PMC7433142 DOI: 10.1186/s12904-020-00633-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background The supportive hospice aged residential exchange (SHARE) is a new model of palliative care education that has been designed for residential aged care. The goal of SHARE is to help clinical staff improve palliative care within residential aged care facilities and to improve specialist palliative care nurses’ knowledge and skill to care for frail older people. Method The experiences of 18 bereaved families concerning the palliative care journey (both at the start and finish of a one-year implementation of SHARE) were explored using semi-structured interviews. Results Three themes were important to bereaved families’ experience: communication with staff, systems of care, and hospice involvement. Sub-themes indicating changes in these three components of care between the start and finish of SHARE was identified. A fourth theme highlighted challenges (relationship with GP, staff shortages, and turnover) that continued across SHARE. Conclusion Findings indicated that SHARE benefited families (improved communication and support) through the end of life journey of their relatives, but challenges remained.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Sophia Barham
- Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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Factors affecting quality of end-of-life hospital care - a qualitative analysis of free text comments from the i-CODE survey in Norway. BMC Palliat Care 2020; 19:98. [PMID: 32635903 PMCID: PMC7341649 DOI: 10.1186/s12904-020-00609-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/28/2020] [Indexed: 12/30/2022] Open
Abstract
Background The ERANet-LAC CODE (Care Of the Dying Evaluation) international survey assessed quality of care for dying cancer patients in seven countries, by use of the i-CODE questionnaire completed by bereaved relatives. The aim of this sub study was to explore which factors improve or reduce quality of end-of-life (EOL) care from Norwegian relatives’ point of view, as expressed in free text comments. Methods 194 relatives of cancer patients dying in seven Norwegian hospitals completed the i-CODE questionnaire 6–8 weeks after bereavement; recruitment period 14 months; response rate 58%. Responders were similar to non-responders in terms of demographic details.104 participants (58% spouse/partner) added free text comments, which were analyzed by systematic text condensation. Results Of the 104 comments, 45% contained negative descriptions, 27% positive and 23% mixed. 78% described previous experiences, whereas 22% alluded to the last 2 days of life. 64% of the comments represented medical/surgical/oncological wards and 36% palliative care units. Four main categories were developed from the free text comments: 1) Participants described how attentive care towards the practical needs of patients and relatives promoted dignity at the end of life, which could easily be lost when this awareness was missing. 2) They experienced that lack of staff, care continuity, professional competence or healthcare service coordination caused uncertainty and poor symptom alleviation. 3) Inadequate information to patient and family members generated unpredictable and distressing final illness trajectories. 4) Availability and professional support from healthcare providers created safety and enhanced coping in a difficult situation. Conclusions Our findings suggest that hospitals caring for cancer patients at the end of life and their relatives, should systematically identify and attend to practical needs, as well as address important organizational issues. Education of staff members ought to emphasize how professional conduct and communication fundamentally affect patient care and relatives’ coping.
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Puente-Fernández D, Campos-Calderón CP, Esteban-Burgos AA, Hueso-Montoro C, Roldán-López CB, Montoya-Juárez R. Palliative Care Symptoms, Outcomes, and Interventions for Chronic Advanced Patients in Spanish Nursing Homes with and without Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1465. [PMID: 32106468 PMCID: PMC7084766 DOI: 10.3390/ijerph17051465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 01/17/2023]
Abstract
The aim of this study was to compare the symptomatology, palliative care outcomes, therapeutic procedures, diagnostic tests, and pharmacological treatments for people with dementia (PWD) and without dementia (PW/OD) admitted to Spanish nursing homes. DESIGN This was a cross-sectional study which is part of a long-term prospective follow-up of elderly people performed in nursing homes to measure end-of-life care processes. PARTICIPANTS 107 nursing home patients with advanced or terminal chronic diseases were selected according to the criteria of the Palliative Care Spanish Society. SETTING Two trained nurses from each nursing home were responsible for participant selection and data collection. They must have treated the residents and had a minimum seniority of 6 months in the nursing home. MEASUREMENTS Sociodemographic data; Edmonton Symptom Assessment Scale; Palliative Care Outcome Scale; and prevalence of diagnostic tests, pharmacological treatments, and therapeutic procedures were evaluated. RESULTS Pain, fatigue, and nausea were found to be significantly higher in the nondementia group and insomnia, poor appetite, and drowsiness were significantly higher in the dementia group. Patient anxiety, support, feeling that life was worth living, self-worth, and practical matters management were higher in the nondementia group. Regarding drugs, use of corticoids was higher in the nondementia group, while use of anxiolytics was higher in the dementia group. Diagnostic procedures such as urine analysis and X-ray were higher in the dementia group. CONCLUSIONS Differences in symptom perception, diagnostic tests, and pharmacological procedures were found between patients with and without dementia. Specific diagnostic tools need to be developed for patients with dementia.
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Affiliation(s)
- Daniel Puente-Fernández
- Doctoral Programme in Clinical Medicine and Public Health, University of Granada, 18012 Granada, Spain;
| | | | - Ana Alejandra Esteban-Burgos
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18016 Granada, Spain; (A.A.E.-B.); (C.H.-M.); (R.M.-J.)
| | - César Hueso-Montoro
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18016 Granada, Spain; (A.A.E.-B.); (C.H.-M.); (R.M.-J.)
- Mind, Brain and Behaviour Research Institute, University of Granada, 18071 Granada, Spain
| | | | - Rafael Montoya-Juárez
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18016 Granada, Spain; (A.A.E.-B.); (C.H.-M.); (R.M.-J.)
- Mind, Brain and Behaviour Research Institute, University of Granada, 18071 Granada, Spain
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Sævareid TJL, Thoresen L, Gjerberg E, Lillemoen L, Pedersen R. Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial. PATIENT EDUCATION AND COUNSELING 2019; 102:2183-2191. [PMID: 31200952 DOI: 10.1016/j.pec.2019.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment. METHODS This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate. RESULTS In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased. CONCLUSION Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach. PRACTICE IMPLICATIONS Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning. TRIAL REGISTRATION ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.
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Affiliation(s)
- Trygve J L Sævareid
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway; Department of Health Sciences, University of Oslo, Forskningsveien 3A Harald Schjelderups hus, 0373, Oslo, Norway.
| | - Elisabeth Gjerberg
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Lillian Lillemoen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
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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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Rosén H, Behm L, Wallerstedt B, Ahlström G. Being the next of kin of an older person living in a nursing home: an interview study about quality of life. BMC Geriatr 2019; 19:324. [PMID: 31752709 PMCID: PMC6873432 DOI: 10.1186/s12877-019-1343-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background The length of stay in nursing homes before death in Sweden has significantly decreased, and nearly one-third of people die within 6 weeks of entering a nursing home. Support for the next of kin is one of the cornerstones of palliative care, but the principles are not always adhered to as recommended when caring for the elderly, which can affect the quality of life of their next of kin. The aim of this study was to explore the experiences of quality of life among the next of kin of older persons who live in nursing homes before an educational intervention of palliative care. Methods This is an explorative qualitative interview study with 40 next of kin using qualitative content analysis performed at baseline before the implementation of the principles of palliative care in nursing homes. Results The next of kin’s experiences of quality of life were expressed in three themes: Orientation to the new life situation, Challenges in their relationship and the Significance of the quality of care in the nursing home. The next of kin experienced a sense of relief, although the older person was constantly on their minds, and they could feel lonely. The difference in the couple’slife situations was experienced as burdensome by the next of kin. The challenges in the relationship were described as stressful, related to a guilty conscience and the older person’s vulnerability. The nursing home could be a context facilitating good relations. The perceptions of quality of care in terms of person-centredness affected the quality of life of the next of kin. Conclusions The findings show that four factors are decisive for the quality of life of next of kin: the relationships within the family, the degree of relief that nursing home care entails as compared to home care, the older person’s health status and whether the care is person-centred. Increased knowledge and education regarding palliative care in nursing homes are needed to better meet the needs of next of kin. Implementation of palliative care should take into account the need for support for next of kin. Trial registration NCT02708498, 15 March 2016.
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Affiliation(s)
- Helena Rosén
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, SE-221 00, Sweden.
| | - Lina Behm
- Faculty of Health Science, Kristianstad University, Kristianstad, SE-291 88, Sweden
| | - Birgitta Wallerstedt
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95, Växjö, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, SE-221 00, Sweden
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Andersson S, Lindqvist O, Fürst CJ, Brännström M. Family members' experiences of care of the dying in residential care homes where the Liverpool Care Pathway was used. Int J Palliat Nurs 2019; 24:194-202. [PMID: 29703112 DOI: 10.12968/ijpn.2018.24.4.194] [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] [Indexed: 11/11/2022]
Abstract
BACKGROUND Residential care homes (RCHs) are increasingly becoming a common place of death for older people. AIM The aim of this study was to describe family members' experiences of care of the dying in RCHs where the Liverpool care pathway for the dying patient was used. METHODS This study had a descriptive qualitative study design. Fifteen (n=15) individual interviews were analysed using qualitative content analysis. RESULTS The analysis resulted in three themes: being confident in a familiar and warm atmosphere, being involved vs not being involved in end-of-life (EoL) care, and being consoled by witnessing the health professional's endeavour to relieve suffering. SIGNIFICANCE OF RESULTS The results indicated that taking part in a care plan seems to increase family members' feelings of involvement in EoL care. This study also highlights the family members' needs for increased possibilities for EoL discussions with the GP.
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Affiliation(s)
- Sofia Andersson
- Registered Nurse, PhD student, Department of Nursing, Umeå University, Umeå, Sweden
| | - Olav Lindqvist
- Registered Nurse, Senior lecturer, Department of Nursing, Umeå University; Department of Learning, Informatics, Management and Ethics/Division of Innovative Care, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Johan Fürst
- Professor, The Institute for Palliative Care, Faculty of Medicine, Department of Clinical Science, Lund University and Region Skåne, Lund, Sweden
| | - Margareta Brännström
- Registered Nurse, Associate Professor, Senior lecturer, Department of Nursing, Umeå; The Arctic Research Centre, Umeå University; Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University
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Lennard C. Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness. ACTA ACUST UNITED AC 2019; 27:1261-1267. [PMID: 30457382 DOI: 10.12968/bjon.2018.27.21.1261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.
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Affiliation(s)
- Chris Lennard
- Registered mental health nurse, Pirton Grange Specialist Care Centre, Pirton, Worcestershire
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Hall A, Rowland C, Grande G. How Should End-of-Life Advance Care Planning Discussions Be Implemented According to Patients and Informal Carers? A Qualitative Review of Reviews. J Pain Symptom Manage 2019; 58:311-335. [PMID: 31004772 DOI: 10.1016/j.jpainsymman.2019.04.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/16/2022]
Abstract
CONTEXT The goal of advance care planning (ACP) is to help ensure that the care people receive during periods of serious illness is consistent with their preferences and values. There is a lack of clear understanding about how patients and their informal carers feel ACP discussions should be implemented. OBJECTIVES The objective of this study was to synthesize literature reviews pertaining to patients' and informal carers' perspectives on ACP discussions. METHODS This is a systematic review of reviews. RESULTS We identified 55 literature reviews published between 2007 and 2018. ACP discussions were facilitated by a diverse range of formats and tools, all of which were acceptable to patients and carers. Patients and carers preferred health professionals to initiate discussions, with the relationships they had with the professionals being particularly important. There were mixed feelings about the best timing, with many people preferring to defer discussions until they perceived them to be clinically relevant. ACP was felt to bring benefits including a greater sense of peace and less worry, but it could also be disruptive and distressing. Patients and carers perceived many benefits from ACP discussions, but these may differ from the dominant narratives about ACP in health policy and may move away from the narratives of RCTs and standardization in research and practice. CONCLUSION Researchers and clinicians may need to adjust their approaches as current practices are not aligned enough with patients' and carers' preferences. Future research may need to test implementation strategies of ACP interventions to elucidate how benefits from standardization and flexibility might both be realized.
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Affiliation(s)
- Alex Hall
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK.
| | - Christine Rowland
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK
| | - Gunn Grande
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Greater Manchester, UK
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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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Physician Visits and Recognition of Residents' Terminal Phase in Long-Term Care Facilities: Findings From the PACE Cross-Sectional Study in 6 EU Countries. J Am Med Dir Assoc 2019; 20:696-702.e1. [DOI: 10.1016/j.jamda.2018.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/22/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
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Tan WS, Car J, Lall P, Low CK, Ho AHY. Implementing Advance Care Planning in Acute Hospitals: Leading the Transformation of Norms. J Am Geriatr Soc 2019; 67:1278-1285. [PMID: 30854643 DOI: 10.1111/jgs.15857] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/17/2019] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite being simply defined as a process to further one's understanding about future medical care, the process of implementing advance care planning (ACP) within acute hospital settings can be complex. AIM We describe different ACP service models adopted in Singapore, and the facilitators for, and barriers to, its effective implementation. DESIGN Qualitative focus group study with thematic analysis. SETTINGS/PARTICIPANTS We purposefully sampled four stakeholder groups involved in the implementation of ACP. Our sample included 63 participants, 12 physicians, 15 nurses, 24 medical social workers, and 12 ACP coordinators from seven public hospitals and one specialist center. RESULTS We describe three different acute-care models adopted in Singapore, differentiated by leadership approach, target population, delivery process, and job roles. Our results revealed nine themes, organized into four categories, including: (1) hospital culture (curative norms, absence of preference-supportive culture), (2) organizational priority and leadership (low priority on hospital agenda, inappropriate leadership), (3) goals and distinction (lack of shared purpose and goals, no clear differentiation from existing practices), and (4) work practices (pigeonholing of ACP practice, inappropriate resourcing, accountability and feedback). CONCLUSION We learned that to implement ACP effectively in an acute-care setting, there needs to be a cultural and behavioral transformation, led by committed and empowered leaders. Organizations that can create a shared purpose built on an ethos of honoring patients' preferences, and support this with systematic processes and adequate resourcing, will be more equipped to implement ACP effectively.
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Affiliation(s)
- Woan Shin Tan
- Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore.,Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Global Digital Health Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Priya Lall
- School of Geography, Queen Mary University of London, London, United Kingdom
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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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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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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Bamford C, Lee R, McLellan E, Poole M, Harrison-Dening K, Hughes J, Robinson L, Exley C. What enables good end of life care for people with dementia? A multi-method qualitative study with key stakeholders. BMC Geriatr 2018; 18:302. [PMID: 30514221 PMCID: PMC6280541 DOI: 10.1186/s12877-018-0983-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND People with advanced dementia often experience suboptimal end of life care (EoLC) with inadequate pain control, increased hospitalisation, and fewer palliative care interventions compared to those with cancer. Existing policy, guidance and recommendations are based largely on expert opinion because of a shortage of high quality, empirical research. Previous studies have tended to consider the views and experience of particular groups. Whilst providing important evidence, they do not take into account the diversity of perspectives of different stakeholders. The Supporting Excellence in End of life care in Dementia (SEED) programme involved multiple stakeholder groups and an integrative analysis to identify key components of good EoLC for people with dementia and to inform a new intervention. METHODS The views of national experts, service managers, frontline staff, people with dementia and family carers were explored using a range of qualitative methods (semi-structured interviews, focus groups, discussions and observations of routine care). The large dataset comprises 116 interviews, 12 focus groups and 256 h of observation. Each dataset was initially analysed thematically prior to an integrative analysis, which drew out key themes across stakeholder groups. RESULTS Through the integrative analysis seven key factors required for the delivery of good EoLC for people with dementia were identified: timely planning discussions; recognition of end of life and provision of supportive care; co-ordination of care; effective working relationships with primary care; managing hospitalisation; continuing care after death; and valuing staff and ongoing learning. These factors span the entire illness trajectory from planning at a relatively early stage in the illness to continuing care after death. CONCLUSIONS This unique study has confirmed the relevance of much of the content of existing end of life frameworks to dementia. It has highlighted seven key areas that are particularly important in dementia care. The data are being used to develop an evidence-based intervention to support professionals to deliver better EoLC in dementia.
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Affiliation(s)
- Claire Bamford
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Richard Lee
- Department of Social Work, Education and Community Wellbeing, Faculty of Health & Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Emma McLellan
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Marie Poole
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | | | - Julian Hughes
- Bristol Medical School, Population and Health Sciences, University of Bristol, Bristol, BS8 2PS UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Catherine Exley
- Health and Life Sciences, Northumbria University, Room NB266, Northumberland Building, College Street, Newcastle upon Tyne, NE1 8ST UK
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Aasmul I, Husebo BS, Sampson EL, Flo E. Advance Care Planning in Nursing Homes - Improving the Communication Among Patient, Family, and Staff: Results From a Cluster Randomized Controlled Trial (COSMOS). Front Psychol 2018; 9:2284. [PMID: 30564163 PMCID: PMC6289020 DOI: 10.3389/fpsyg.2018.02284] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 11/02/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction: The majority of nursing home (NH) patients suffer from complex diseases, including dementia. This makes advance care planning (ACP) particularly important. Objectives: The aim was to investigate the effect of an ACP intervention on communication among NH staff, patient, and family. We further investigated whether the intervention affected nursing staff distress. Methods: The ACP intervention was a part of the 4-month cluster randomized controlled COSMOS trial with a 9-month follow-up. Norwegian NH units (n = 72), with 765 patients were invited, and eligible units were cluster randomized to usual care or the intervention group. The ACP intervention consisted of an education program targeting all NH staff (nurses and physicians) and managers. Implementation was supported by a train-the-trainer approach, with regular phone calls from the researchers. The effect of the intervention was assessed by a data collection form and questionnaires. Nursing staff distress was assessed by the Neuropsychiatric Inventory -Nursing Home version. Results: Five hundred and forty five patients from 67 NH units were included and randomized to the intervention (N = 297; 36 units) and control group (N = 248; 31 units). Organized meetings between the family, patient, and nurses were conducted more frequently in the intervention compared to the control group at month 4 (OR = 3.9, 95% CI = 1.6 to 9.4, p = 0.002). Monthly contact between family and nurses was also more frequent in the intervention group (OR = 6.5, 95% CI = 1.6 to 3.5, p = 0.010). Nurses and families were more satisfied with their communication in the intervention compared to the control group. Staff distress was reduced in the intervention group at month 4 (B = -1.8, 95% CI = -3.1 to -0.4, p = 0.012). The intervention effect at month 4 did not persist during follow-up at month 9. Conclusion: Compared to control, the ACP intervention improved the communication, and family and staff satisfaction as well as reduced staff distress. However, during the follow-up period these positive effects were not persistent. Indicating the necessity for ongoing staff support regarding ACP. Trial Registration:www.ClinicalTrials.gov (NCT02238652).
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Affiliation(s)
- Irene Aasmul
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Nursing Home Medicine, Bergen, Norway
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Elisabeth Flo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway
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Jóhannesdóttir S, Hjörleifsdóttir E. Communication is more than just a conversation: family members' satisfaction with end-of-life care. Int J Palliat Nurs 2018; 24:483-491. [DOI: 10.12968/ijpn.2018.24.10.483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Elísabet Hjörleifsdóttir
- Associate professor, Faculty of Nursing, School of Health Sciences, University of Akureyri, Akureyri, Iceland
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43
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Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage 2018; 56:436-459.e25. [PMID: 29807158 DOI: 10.1016/j.jpainsymman.2018.05.016] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. AIM The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice. DESIGN An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis. RESULTS Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders. CONCLUSIONS Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.
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Affiliation(s)
- Geronimo Jimenez
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Woan Shin Tan
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; NTU Institute of Health Technologies (HealthTech), Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore; Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Amrit K Virk
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chan Kee Low
- Economics Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Andy Hau Yan Ho
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Psychology Programme, School of Social Sciences, Nanyang Technological University, Singapore, Singapore; Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
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44
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O'Hanlon CE, Walling AM, Okeke E, Stevenson S, Wenger NS. A Framework to Guide Economic Analysis of Advance Care Planning. J Palliat Med 2018; 21:1480-1485. [PMID: 30096252 DOI: 10.1089/jpm.2018.0041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is fundamental to guiding medical care at the end of life. Understanding the economic impact of ACP is critical to implementation, but most economic evaluations of ACP focus on only a few actors, such as hospitals. OBJECTIVE To develop a framework for understanding and quantifying the economic effects of ACP, particularly its distributional consequences, for use in economic evaluations. DESIGN Literature review of economic analyses of ACP and related costs to estimate magnitude and direction of costs and benefits for each actor and how data on these costs and benefits could be obtained or estimated. RESULTS ACP can lead to more efficient allocation of resources by reducing low-value care and reallocating resources to high-value care, and can increase welfare by aligning care to patient preferences. This economic framework considers the costs and benefits of ACP that accrue to or are borne by six actors: the patient, the patient's family and caregivers, healthcare providers, acute care settings, subacute and home care settings, and payers. Program implementation costs and nonhealthcare costs, such as time costs borne by patients and caregivers, are included. Findings suggest that out-of-pocket costs for patients and families will likely change if subacute or home care is substituted for acute care, and subacute care utilization is likely to increase while primary healthcare providers and acute care settings may experience heterogeneous effects. CONCLUSIONS A comprehensive economic evaluation of ACP should consider how costs and benefits accrue to different actors.
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Affiliation(s)
- Claire E O'Hanlon
- 1 Pardee RAND Graduate School , RAND Corporation, Santa Monica, California
| | - Anne M Walling
- 2 Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California.,3 Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles , Los Angeles, California.,4 RAND Health, RAND Corporation, Santa Monica, California
| | | | - Sharon Stevenson
- 6 Bellweather Care, Inc. and Okapi Venture Capital, Laguna Beach, California
| | - Neil S Wenger
- 3 Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles , Los Angeles, California.,4 RAND Health, RAND Corporation, Santa Monica, California
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Barriers to Promoting Advance Care Planning for Residents Living in a Sanatorium for Hansen's Disease: A Qualitative Study of Residents and Staff in Japan. Asian Bioeth Rev 2018; 10:199-217. [PMID: 30464777 PMCID: PMC6223884 DOI: 10.1007/s41649-018-0059-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/12/2018] [Indexed: 11/03/2022] Open
Abstract
In Japan, most residents with Hansen's disease (leprosy) live in dedicated sanatoria because of an established quarantine policy, even after being cured of the primary disease. They suffer from secondary diseases and are advancing in age, and advance care planning (ACP) is increasingly crucial for them to live their lives with dignity in a sanatorium. In this study, we have three aims: (1) to understand how to promote communication about their wishes for medical treatment, care, and recuperation; (2) to identify required assistance; and (3) to explore how to promote ACP in a sanatorium. This study is a qualitative research conducted through semi-structured interviews. The study included 57 ex-Hansen's disease patients and 66 staff (10 doctors, 27 nurses, 23 care workers, and 6 social workers) from 10 facilities. Ex-Hansen's disease patients were expected to consider ACP, but this was in the context of uncertainty about whether a sanatorium would close and whether there would be doctors to manage their needs. They reported being confused when staff rushed to confirm their advance directives, feeling that they were not provided with enough information before being approached. Barriers to promoting ACP were found to be insufficient of team-based care and information sharing, ex-Hansen's disease patients' weak interest in their end of life, and their conservative thoughts. We believe that ACP can be achieved by listening to the wishes of recovered patients through regular home care visits by nurses and everyday support by care workers. Furthermore, multidisciplinary coordination is urgently needed for promoting ACP.
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State of advance care planning research: A descriptive overview of systematic reviews. Palliat Support Care 2018; 17:234-244. [PMID: 30058506 DOI: 10.1017/s1478951518000500] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes. METHOD Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches. RESULT Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes. SIGNIFICANCE OF RESULTS Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
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Tilburgs B, Vernooij-Dassen M, Koopmans R, van Gennip H, Engels Y, Perry M. Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review. PLoS One 2018; 13:e0198535. [PMID: 29924837 PMCID: PMC6010277 DOI: 10.1371/journal.pone.0198535] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 05/21/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Due to the disease's progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied. AIM To determine the barriers and facilitators faced by GPs related to ACP with people with dementia. DATA SOURCES We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl's method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis. RESULTS Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia's decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life. CONCLUSION Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions.
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Affiliation(s)
- Bram Tilburgs
- Department of IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
| | | | - Raymond Koopmans
- Department of Primary and Community Care, Radboudumc, Nijmegen, The Netherlands
- Radboudumc Alzheimer Centre, Nijmegen, The Netherlands
- Joachim and Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
| | - Hans van Gennip
- Independent Educational Researcher, Family carer, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Marieke Perry
- Department of Primary and Community Care, Radboudumc, Nijmegen, The Netherlands
- Radboudumc Alzheimer Centre, Nijmegen, The Netherlands
- Department of Geriatric Medicine, Radboudumc, Nijmegen, The Netherlands
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Greenwood N, Menzies-Gow E, Nilsson D, Aubrey D, Emery CL, Richardson A. Experiences of older people dying in nursing homes: a narrative systematic review of qualitative studies. BMJ Open 2018; 8:e021285. [PMID: 29866732 PMCID: PMC5988179 DOI: 10.1136/bmjopen-2017-021285] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To identify and synthesise qualitative research from 2001 investigating older people's (65+ years) experiences of dying in nursing and care homes. METHODS AND OUTCOMES Eight electronic databases (AMED, ASSIA, CINAHL Plus, Embase, HMIC, Medline, PsychINFO and Scopus) from 2001 to July 2017 were searched. Studies were included if they were qualitative, primary research and described the experiences of dying in nursing or care homes from the perspectives of the older people themselves, their families or staff. Study quality assessment was undertaken to systematically assess methodological quality, but no studies were excluded as a result. RESULTS 1305 articles were identified. Nine met the inclusion criteria. North American studies dominated. Most used a mixture of observations and interviews. All the included studies highlighted the physical discomfort of dying, with many older people experiencing potentially avoidable symptoms if care were to be improved. Negative psychosocial experiences such as loneliness and depression were also often described in addition to limited support with spiritual needs. CONCLUSIONS More qualitative research giving a holistic understanding of older people's experiences of dying in residential care homes is needed. Undertaking research on this topic is challenging and requires great sensitivity, but the dearth of qualitative research from the perspectives of those most closely involved in older people's deaths hampers service improvement.
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Affiliation(s)
- Nan Greenwood
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Emma Menzies-Gow
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - David Nilsson
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Dawn Aubrey
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Claire L Emery
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - Angela Richardson
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
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Wallerstedt B, Behm L, Alftberg Å, Sandgren A, Benzein E, Nilsen P, Ahlström G. Striking a Balance: A Qualitative Study of Next of Kin Participation in the Care of Older Persons in Nursing Homes in Sweden. Healthcare (Basel) 2018; 6:healthcare6020046. [PMID: 29751660 PMCID: PMC6023303 DOI: 10.3390/healthcare6020046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022] Open
Abstract
Most of the care in nursing homes is palliative in nature, as it is the oldest and the frailest people who live in nursing homes. The aim of this study was to explore next of kin's experiences of participating in the care of older persons at nursing homes. A qualitative design was used, based on semi-structured interviews with 40 next of kin, and analyzed using qualitative content analysis. An overarching theme emerged, a balancing act consisting of three categories: (1) visiting the nursing home; (2) building and maintaining relationships; and (3) gathering and conveying information. The next of kin have to balance their own responsibility for the older person's wellbeing by taking part in their care and their need to leave the responsibility to the staff due to critical health conditions. The next of kin wanted to participate in care meetings and conversations, not only in practical issues. The findings indicate the need to improve the next of kin's participation in the care as an equal partner. Increased knowledge about palliative care and decision-making of limiting life-prolonging treatment may lead to a higher quality of care.
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Affiliation(s)
- Birgitta Wallerstedt
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Lina Behm
- Department of Health Sciences, Faculty of Medicine, Lund University, SE-221 00 Lund, Sweden.
| | - Åsa Alftberg
- Department of Social Work, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Eva Benzein
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Per Nilsen
- Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden.
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, SE-221 00 Lund, Sweden.
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Klomstad K, Pedersen R, Førde R, Romøren M. Involvement in decisions about intravenous treatment for nursing home patients: nursing homes versus hospital wards. BMC Med Ethics 2018; 19:34. [PMID: 29739393 PMCID: PMC5941318 DOI: 10.1186/s12910-018-0258-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient’s best interest, assessment of capacity to consent, and on the patient’s own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards. Methods Using a questionnaire, we studied the decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 (72%) patients treated in nursing homes to the 84 (28%) nursing home patients treated in the hospital. Results The patients’ capacity to consent was considered prior to treatment in 197 (92%) of the patients treated in nursing homes and 56 (67%) of the patients treated in hospitals (p < 0.001). The answers indicate that capacity to consent can be difficult to assess. Patients that were considered capable to consent, were more often involved in the decision-making in nursing homes than in hospital (90% vs. 52%). Next of kin and other health personnel were also more rarely involved when the nursing home patient was treated in hospital. Whether advance care planning had been carried out, was more often unknown in the hospital (69% vs. 17% in nursing homes). Hospital doctors expressed more doubt about the decision to admit the patient to the hospital than about the treatment itself. Conclusions This study indicates a potential for improvement in decision-making processes in general, and in particular when nursing home patients are treated in a hospital ward. The findings corroborate that nursing home patients should be treated locally if adequate health care and treatment is available. The communication between the different levels of health care when hospitalization is necessary, must be better. Trial registration ClinicalTrials.gov NCT01023763 (12/1/09) [The registration was delayed one month after study onset due to practical reasons]. Electronic supplementary material The online version of this article (10.1186/s12910-018-0258-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristin Klomstad
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway. .,Antibiotic centre for primary care, Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway.
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