Advance Care Planning in Long-Term Care Facilities

Evaluation of the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme: a protocol of a cluster randomised control trial

INTRODUCTION

Despite the high mortality rates in long-term care (LTC) homes, most do not have a formalised palliative programme. Hence, our research team has developed the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme. The goal of the proposed study is to examine the implementation and effectiveness of the SPA-LTC programme.

METHODS AND ANALYSIS

A cross-jurisdictional, effectiveness-implementation type II hybrid cluster randomised control trial design will be used to assess the SPA-LTC programme for 18 LTC homes (six homes within each of three provinces). Randomisation will occur at the level of the LTC home within each province, using a 1:1 ratio (three homes in the intervention and control groups). Baseline staff surveys will take place over a 3-month period at the beginning for both the intervention and control groups. The intervention group will then receive facilitated training and education for staff, and residents and their family members will participate in the SPA-LTC programme. Postintervention data collection will be conducted in a similar manner as in the baseline period for both groups. The overall target sample size will be 594 (297 per arm, 33 resident/family member participants per home, 18 homes). Data collection and analysis will involve organisational, staff, resident and family measures. The primary outcome will be a binary measure capturing any emergency department use in the last 6 months of life (resident); with secondary outcomes including location of death (resident), satisfaction and decisional conflict (family), knowledge and confidence implementing a palliative approach (staff), along with implementation outcomes (ie, feasibility, reach, fidelity and perceived sustainability of the SPA-LTC programme). The primary outcome will be analysed via multivariable logistic regression using generalised estimating equations. Intention-to-treat principles will be used in the analysis.

ETHICS AND DISSEMINATION

The study has received ethical approval. Results will be disseminated at various presentations and feedback sessions; at provincial, national and international conferences, and in a series of manuscripts that will be submitted to peer-reviewed, open access journals.

TRIAL REGISTRATION NUMBER

NCT039359.

The family surrogates' psychological experience of making a do-not-resuscitate decision for older relatives: a qualitative study

BACKGROUND

Many nursing home residents lack autonomous decision-making capacity and rely on family members to make do-not-resuscitate (DNR) decisions. Making DNR decisions can be difficult and complicated for surrogates. However, surrogates' psychological experience in making these decisions for older relatives is not well studied.

AIM

To understand the surrogates' psychological experience of making DNR decisions for older relatives in a nursing home.

METHODS

The study subjects of this qualitative study were family surrogates of older residents in a nursing home of Taiwan. A self-constructed, semi-structured interview guided in-depth interviews, which were recorded. Content analysis was used to discover themes from verbatim record.

RESULTS

Four themes were revealed: lack of psychological preparation, considering issues when making a decision, ambivalent emotional responses and impact of cultural factors. Fifteen subthemes were also found.

CONCLUSIONS

Surrogates who must decide whether to make a DNR decision for older relatives experience great emotional conflict. Understanding surrogates' struggles may assist nursing and care staff in managing this difficult situation.

Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review

BACKGROUND

Advance care planning and goals of care discussions involve the exploration of what is most important to a person, including their values and beliefs in preparation for health-care decision-making. Advance care planning conversations focus on planning for future health care, ensuring that an incapable person's wishes are known and can guide the person's substitute decision maker for future decision-making. Goals of care discussions focus on preparing for current decision-making by ensuring the person's goals guide this process.

AIM

To provide evidence regarding tools and/or practices available for use by health-care providers to effectively facilitate advance care planning conversations and/or goals of care discussions.

DATA SOURCES

A systematic review was conducted focusing on guidelines, randomized trials, comparative studies, and noncomparative studies. Databases searched included MEDLINE, EMBASE, and the proceedings of the International Advance Care Planning Conference and the American Society of Clinical Oncology Palliative Care Symposium.

CONCLUSIONS

Although several studies report positive findings, there is a lack of consistent patient outcome evidence to support any one clinical tool for use in advance care planning or goals of care discussions. Effective advance care planning conversations at both the population and the individual level require provider education and communication skill development, standardized and accessible documentation, quality improvement initiatives, and system-wide coordination to impact the population level. There is a need for research focused on goals of care discussions, to clarify the purpose and expected outcomes of these discussions, and to clearly differentiate goals of care from advance care planning.

Measuring Family Members' Satisfaction with End-of-Life Care in Long-Term Care: Adaptation of the CANHELP Lite Questionnaire

RATIONALE

Improving end-of-life care (EOLC) in long-term care (LTC) homes requires quality measurement tools that assess families' satisfaction with care. This research adapted and pilot-tested an EOLC satisfaction measure (Canadian Health Care Evaluation Project (CANHELP) Lite Questionnaire) for use in LTC to measure families' perceptions of the EOLC experience and to be self-administered.

METHODS AND RESULTS

Phase 1. A literature review identified key domains of satisfaction with EOLC in LTC, and original survey items were assessed for inclusiveness and relevance. Items were modified, and one item was added.

PHASE 2

The revised questionnaire was administered to 118 LTC family members and cognitive interviews were conducted. Further modifications were made including reformatting to be self-administered.

PHASE 3

The new instrument was pilot-tested with 134 family members. Importance ratings indicated good content and face validity. Cronbach's alpha coefficients (range: .88-.94) indicated internal consistency.

CONCLUSION

This research adapted and pilot-tested the CANHELP for use in LTC. This paper introduces the new, valid, internally consistent, self-administered tool (CANHELP Lite Family Caregiver LTC) that can be used to measure families' perceptions of and satisfaction with EOLC. Future research should further validate the instrument and test its usefulness for quality improvement and care planning.

Concept analysis of good death in long term care residents

The purpose of this concept analysis paper is to delineate the meaning of good death in long term care (LTC) settings and examine its implications for nursing. The Walker and Avant (2011) method was chosen for this analysis. An in depth literature review identifies uses of the concept and determines the defining attributes of the good death. This paper also illustrates case presentations, antecedents, consequences, empirical referents and implications for clinical practice to clarify the concept of 'good death' in this population. In LTC, death is experienced frequently and is considered the ultimate outcome for most admissions. Much of the existing research on end-of-life care has focused on community dwelling cancer patients whose death trajectory is predictable and who may remain cognitively intact until actively dying. In contrast, the LTC population is older and more likely to suffer from dementia and experience chronic illness for long periods prior to death, and they follow a less predictable death trajectory. In this century, death became the province of older people and the assurance of a good death became the responsibility of those caring for them.

General practitioners perceptions on advance care planning for patients living with dementia

Background

Advance care planning (ACP) facilitates communication and understanding of preferences, nevertheless the use of ACPs in primary care is low. The uncertain course of dementia and the inability to communicate with the patient living with dementia are significant challenges for GPs to initiate discussions on goals of care.

Methods

A cross-sectional survey, using a purposive, cluster sample of GPs across Northern Ireland with registered dementia patients was used. GPs at selected practices received the survey instrument and up to four mail contacts was implemented.

Results

One hundred and thirty-three GPs (40.6%) participated in the survey, representing 60.9% of surveyed practices. While most respondents regarded dementia as a terminal disease (96.2%) only 37.6% felt that palliative care applied equally from the time of diagnosis to severe dementia. While most respondents thought that early discussions would facilitate decision-making during advanced dementia (61%), respondents were divided on whether ACP should be initiated at the time of diagnoses. While most respondents felt that GPs should take the initiative to introduce and encourage ACP, most survey participants acknowledged the need for improved knowledge to involve families in caring for patients with dementia at the end of life and that a standard format for ACP documentation was needed.

Conclusion

Optimal timing of ACP discussions should be determined by the readiness of the patient and family carer to face end of life. ACP discussions can be enhanced by educational strategies directed towards the patient and family carer that enable shared decision-making with their GP when considering options in future care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0019-x) contains supplementary material, which is available to authorized users.

Palliative care health professionals’ experiences of caring for patients with advance care directives

Objective To explore the health professionals’ (HPs) perceptions and experiences of advance care directives (ACDs) and advance care planning in Australian palliative care services. Methods A nationwide survey of 105 palliative care services was conducted, with two HPs from each service invited to participate. A qualitative analysis of open responses about advance care planning was undertaken. Results Sixty questionnaires were returned with open responses. Most responders were nurses (75%), aged ≥40 years (80%) and with a mean of 12 years palliative care experience. Data were grouped into four key themes: (1) the ACD; (2) the process of developing ACDs; (3) the process of using ACDs; and (4) the consequences of having ACDs. Participants were positive about advance care planning, commenting that ongoing communication about end-of-life care ensures mutual understanding between patients, family and HPs. Provision of care was considered easier and more efficient with an ACD in place. ACDs were perceived to reduce distrust and conflict between family, friends and HPs, and promote communication. Suboptimal documentation, clarity and explicitness limited the usefulness of ACDs when they were available. Conclusions Advance care planning benefits HPs, patients and their family. To maximise these benefits, ACDs need to be clear, comprehensive, medically relevant and transportable documents. What is known about the topic? Ideally, advance care planning encompasses the identification and documentation of a person’s preferences for future medical treatments and care in preparation for an occasion when the person cannot express their values and wishes. The uptake and practice of advance care planning is inconsistent, and the extent to which it is used by health professionals and patients is variable. Many people are cared for at the end of life in specialist palliative care services, but the intersection between palliative care and advance care planning remains under-researched. What does this paper adds? ACDs facilitate communication and advance care planning; help establish trust between health professionals, patients and their families; and make multiple aspects of care easier for HPs. Processes surrounding ACDs, particularly inadequate documentation, limit adherence and application. What are the implications for practitioners? Clear communication is necessary for effective ACD development and application. The presence of an ACD makes communication and advance care planning easier, and improves trust between HPs, patients and their family. To be useful, ACDs must be clear, comprehensive, medically relevant, transportable documents.

Developing Strategies to Improve Advance Care Planning in Long Term Care Homes: Giving Voice to Residents and Their Family Members

Long term care (LTC) homes, also known as residential care homes, commonly care for residents until death, making palliative care and advance care planning (ACP) important elements of care. However, limited research exists on ACP in LTC. In particular, research giving voice to family members and substitute decision makers is lacking. The objective of this research was to understand experiences, perspectives, and preferences to guide quality improvement of ACP in LTC. This qualitative descriptive study conducted 34 individual semistructured interviews in two LTC homes, located in Canada. The participants were 31 family members and three staff, consisting of a front line care worker, a registered nurse, and a nurse practitioner. All participants perceived ACP conversations as valuable to provide “resident-centred care”; however, none of the participants had a good understanding of ACP, limiting its effectiveness. Strategies generated through the research to improve ACP were as follows: educating families and staff on ACP and end-of-life care options; better preparing staff for ACP conversations; providing staff skills training and guidelines; and LTC staff initiating systematic, proactive conversations using careful timing. These strategies can guide quality improvement of palliative care and development of ACP tools and resources specific to the LTC home sector.

A review of advance care planning programs in long-term care homes: are they dementia friendly?

Background. Persons living with dementia in the long-term care home (LTCH) setting have a number of unique needs, including those related to planning for their futures. It is therefore important to understand the advance care planning (ACP) programs that have been developed and their impact in order for LTCH settings to select a program that best suits residents' needs. Methods. Four electronic databases were searched from 1990 to 2013, for studies that evaluated the impact of advance care planning programs implemented in the LTCH setting. Studies were critically reviewed according to rigour, impact, and the consideration of the values of residents with dementia and their family members according to the Dementia Policy Lens Toolkit. Results and Conclusion. Six ACP programs were included in the review, five of which could be considered more “dementia friendly.” The programs indicated a variety of positive impacts in the planning and provision of end-of-life care for residents and their family members, most notably, increased ACP discussion and documentation. In moving forward, it will be important to evaluate the incorporation of residents with dementia's values when designing or implementing ACP interventions in the LTCH settings.

Promoting advance planning for health care and research among older adults: a randomized controlled trial

Background

Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making.

Methods/Design

Dyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments.

Discussion

This study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system.

Trial Registration

ISRCTN89993391

Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device

OBJECTIVE

To gain an understanding of how advance care planning (ACP) is understood and approached by managers of residential aged care facilities.

METHODS

Qualitative interviews with managers from 41 residential aged care facilities from South Western Sydney, Australia. Content and thematic analysis of interview transcripts.

RESULTS

The majority of facilities do not have a systematic approach to ACP, but tend to initiate discussions about end-of-life treatments late in a resident's illness. There are varying degrees to which these discussions are used in ongoing care planning or made explicit if the resident is transferred to hospital. A number of factors are identified that support the implementation of ACP.

CONCLUSION

A continuum model of practice is proposed that describes four broad approaches to practice under the domains of initiation, scope, follow-up and documentation of ACP as well as the organisational leadership adopted around ACP.

Advance care planning in care homes for older people: an English perspective

Advance care planning (ACP) as a process of discussing and recording wishes for future care and treatment is increasingly being promoted and discussed in the UK, reflecting recent changes in legislation. This study describes current ACP practice in care homes for older people drawing on data from a questionnaire survey (n = 213) of, and interviews (n = 15) with, care home managers. Whilst consultation about general care is taking place in the majority of homes surveyed using both formal and informal processes, the number of residents that have completed any ACP processes varies. Managers face intrinsic and extrinsic challenges related to the ascertaining of, and the implementing of wishes as they address ACP in the care home context. Until these wider contextual factors are addressed it will be difficult for staff in care homes to effectively undertake and implement ACP in care homes.

Nursing Home Participation in End-of-Life Programs: United States, 2004

The purpose of this report is to define the extent to which US nursing homes (NH) participate in end-of-life programs, using a nationally representative, cross-sectional sample of US NH. Data on EoL programs including Five Wishes, Last Acts, and Physician Orders for Life-Sustaining Treatment (POLST) were collected. In 2004, 17.2% of NH reported participating in 1 or more of these programs, with the largest proportion participating in POLST (13.3%) and smaller proportions in Five Wishes (5.6%) and Last Acts (4.2%). Nursing homes were more likely to participate in EoL programs if they also offered specialty programs and staff training for hospice, end-of-life, pain management, and dementia services. In 2004, fewer than 1 in 5 US NH participated in an EoL program. However, facilities that had EoL programs were more likely to have programs and staff training for services related to EoL care, a finding that suggests a clustering of these programs, services, and training. Provision of appropriate staff training may be a key to expanding EoL program participation in skilled nursing.

Managed death in a PACE: pathways in present and advance directives

OBJECTIVES

To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes.

DESIGN

Interventional prospective cohort (pre- and post-).

SETTING

Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO.

PARTICIPANTS

Enrolled PACE participants.

INTERVENTION

A documentation tool that captures both present and advance directives in a framework of "pathways," blending goals of care with typical procedure-oriented directives.

MEASUREMENTS

Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death.

RESULTS

Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant.

CONCLUSION

Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life's end, and increased compliance with participants' wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.

Do not hospitalize orders in nursing homes: a pilot study

OBJECTIVES

To determine (1) the point prevalence of do not hospitalize (DNH) policies in nursing facilities directed by members of the American Medical Directors Association (AMDA) Foundation Long-term Care Research Network, (2) the frequency with which physicians are writing DNH orders, and (3) respondent perceptions about the appropriateness of the number of DNH orders as too few or too many and reasons for such perceptions.

DESIGN

Online survey of members of the AMDA Foundation Long-term Care Research Network.

SETTING

Nursing facilities.

PARTICIPANTS

All members of the AMDA Foundation Long-term Research Network on July 1, 2003 were eligible for participation (N = 293).

INTERVENTION

None.

MEASUREMENTS

Demographic information regarding census, region, setting, governance, presence of teaching and/or hospice affiliation, prevalence of DNH orders, and qualitative information regarding the use of DNH orders in each facility.

RESULTS

The response rate was 32% (n = 95). DNH policies were in place for 62% of facilities and the prevalence of DNH orders ranged from 12% to 23% when facilities were stratified by size. Percentage of residents with documented DNH orders ranged from 0% to 99% at individual facilities. No significant differences were found although trends were noted as follows: chain facilities had fewer DNH policies (RR = 0.8; 95% CI = 0.6-1.1) whereas rural facilities (RR = 1.1, 95% CI = 0.8-1.5) and those associated with a teaching institution (RR = 1.1, 95% CI = 0.8-1.5) were more likely to have a DNH policy. Of respondents, 80% indicated that physicians in their facilities were writing DNH orders but 77% believed that the number of DNH orders was too few. Respondents cited overly optimistic prognosis and lack of knowledge about DNH orders as barriers to writing more DNH orders.

CONCLUSION

The prevalence of DNH orders in this investigation is higher than previous estimates from national data samples. Most facilities had a DNH policy and although respondents indicated that physicians do write DNH orders, they believed that DNH orders were not utilized frequently enough. There is a large variation in prevalence of DNH orders across the facilities included in this survey. Barriers to use, as perceived by medical directors, included unrealistic expectations by family, fear of litigation, and staff discomfort with managing residents who experience clinical decline. Nevertheless, DNH orders are used extensively in some facilities associated with members of the AMDA Foundation Long-term Care Research Network.

Factors Affecting Long-Term-Care Residents' Decision-Making Processes as They Formulate Advance Directives

PURPOSE

The purpose of this study was to describe factors contributing to the decision-making processes of elderly persons as they formulate advance directives in long-term care.

DESIGN AND METHODS

This study was qualitative, based on grounded theory. Recruitment was purposive and continued until saturation was reached. Nine residents of a long-term-care facility were interviewed by use of a semistructured format. Open and axial coding of interview transcripts were carried out and the factors contributing to the decision process were defined.

RESULTS

Elders based their decisions primarily on information gathered from personal experiences with death and illness. They obtained very little information from professionals or the media. Major factors considered by elders as they weighed information included spiritual, emotional, and social considerations.

IMPLICATIONS

The factors considered during the decision-making process were oriented more toward the individual's experiences and less on contributions from objective sources than anticipated. Decision making for advance directives is a highly personalized process. The approach of health professionals when assisting with end-of-life decision making should be planned with these contributing factors in mind, so that the services offered to the individuals in this population best meet their needs.

Quality Palliative Care in Long-Term Care Settings

It is paramount that physicians and midlevel practitioners who care for residents in long-term care facilities be able to provide high-quality comfort care to their patients, the majority of whom are frail and suffering from chronic and progressive diseases. Physicians must be knowledgeable in the assessment, prevention, and relief of patients' physical, emotional, and spiritual distress, as well as develop appropriate attitudes, knowledge, and skills to care for patients who are in the last years of life. The provision of high-quality palliative care is the essence of long-term care medicine.