Advance care planning by proxy for residents of long-term care facilities who lack decision-making capacity

Improving Care for Older Adults with Cancer in Canada: A Call to Action

Most patients diagnosed with and dying from cancer in Canada are older adults, with aging contributing to the large projected growth in cancer incidence. Older adults with cancer have unique needs, and on a global scale increasing efforts have been made to address recognized gaps in their cancer care. However, in Canada, geriatric oncology remains a new and developing field. There is increasing recognition of the value of geriatric oncology and there is a growing number of healthcare providers interested in developing the field. While there is an increasing number of dedicated programs in geriatric oncology, they remain limited overall. Developing novel methods to delivery geriatric care in the oncology setting and improving visibility is important. Formal incorporation of a geriatric oncology curriculum into training is critical to both improve knowledge and demonstrate its value to healthcare providers. Although a robust group of dedicated researchers exist, increased collaboration is needed to capitalize on existing expertise. Dedicated funding is critical to promoting clinical programs, research, and training new clinicians and leaders in the field. By addressing challenges and capitalizing on opportunities for improvement, Canada can better meet the unique needs of its aging population with cancer and ultimately improve their outcomes.

Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country

We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.

Process of Advance Care Planning in Nursing Home Settings: An Integrative Literature Review

Advance care planning (ACP) allows individuals to communicate their wishes for future medical care. ACP is particularly important among those diagnosed with Alzheimer's disease and related dementias (ADRD) due to decline in cognition. In the nursing home setting, conducting ACP with residents with ADRD and their family caregivers is challenging. The purpose of the current integrative review was to: (a) examine the evidence on the process of conducting ACP with residents with ADRD and their family caregivers in nursing home settings, and (b) understand who conducts ACP and when and how ACP is being conducted with residents with ADRD and their family caregivers. Gaps were identified, such as lack of a systematic approach to addressing ACP in nursing homes, lack of clear roles in conducting ACP, family caregivers' and nursing home staff's lack of knowledge and skills to engage in ACP, and lack of diversity in study samples. To improve clinical practice, future studies should explore standardization of the ACP process in the nursing home setting. [Research in Gerontological Nursing, xx(x), xx-xx.].

Advance care planning by proxy in German nursing homes: Descriptive analysis and policy implications

BACKGROUND

Legally recognized advance directives (ADs) have to be signed by the person to whom the decisions apply. In practice, however, there are also ADs written and signed by legal proxies (surrogates) on behalf of patients who lack decision-making capacity. Given their practical relevance and substantial ethical and legal implications, ADs by proxy (AD-Ps) have received surprisingly little scientific attention so far.

OBJECTIVES

To study the form, content, validity, and applicability of AD-Ps among German nursing home residents and develop policy implications.

METHODS

Secondary analysis of two independent cross-sectional studies in three German cities, comprising 21 nursing homes and 1528 residents. The identified AD-Ps were analyzed in parallel by three independent raters. Inter-rater agreement was measured using free-marginal multi-rater kappa statistics.

RESULTS

Altogether, 46 AD-Ps were identified and pooled for analysis. On average (range), AD-Ps were 1 (1-7) year(s) old, 0.5 (0.25-4) pages long, signed by 1 (0-5) person, with evidence of legal proxy involvement in 35%, and signed by a physician in 20% of cases. Almost all the AD-Ps reviewed aimed to limit life-sustaining treatment (LST), but had widely varying content and ethical justifications, including references to earlier statements (30%) or actual behavior (11%). The most frequent explicit directives were: do-not-hospitalize (67%), do-not-tube-feed (37%), do-not-attempt-resuscitation (20%), and the general exclusion of any LST (28%). Inter-rater agreement was mostly moderate (kappa ≥0.6) or strong (kappa ≥0.8).

CONCLUSIONS

Although AD-Ps are an empirical reality in German nursing homes, formal standards for such directives are lacking and their ethical justification based on substituted judgment or best interest standard often remains unclear. A qualified advance care planning process and corresponding documentation are required in order to safeguard the appropriate use of this important instrument and ensure adherence to ethico-legal standards.

Palliative and end-of-life care for the older adult with cancer

PURPOSE OF REVIEW

Despite established benefits of palliative care in the oncology population, it remains an underutilized resource particularly among older adults. The illness trajectory and needs of an older adult with cancer are unique. The purpose of this paper is to review the current literature on providing comprehensive palliative and end-of-life care for the older adult with cancer.

RECENT FINDINGS

Though the difficulties of applying traditional palliative care principles in the older patients with cancer have been discussed, this review reveals a clear gap in the literature in discussing the provision of comprehensive palliative and end-of-life care in this population. Very few articles have been published in this domain with even fewer published within the past 18 months.

SUMMARY

As such, this article reviews key aspects of palliative and geriatric medicine that need to be considered and integrated in order to provide comprehensive palliative care to the older adult with cancer. This includes a discussion of proper pain and symptoms assessment, performance status assessment, advance care planning, and end-of-life care while considering the nuances of geriatric syndromes.

Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention

OBJECTIVES

Advance care planning (ACP) is important to ensure that nursing home (NH) residents receive care concordant with their goals. Video interventions have been developed to improve the process of ACP. Yet, little is known about which NH characteristics are associated with implementation of ACP video interventions in clinical practice. Our objective was to examine NH-level characteristics associated with the implementation of an ACP video intervention as part of the Pragmatic trial of Video Education in Nursing Homes (PROVEN) trial.

DESIGN

Cross-sectional study of NHs in PROVEN.

SETTING AND PARTICIPANTS

119 NHs randomized to receive the ACP video intervention.

MEASUREMENTS

The outcomes were the proportion of short- (<100 days) and long-stay (≥100 days) NH residents who were (1) offered to watch a video and (2) shown a video, aggregated to the NH-level, and measured using electronic forms of video offers. The association between outcomes and NH facility characteristics (eg, staffing, resident acuity) and participation in other aspects of the PROVEN trial (eg, monthly check-in calls) were estimated using multivariate linear regression models. NH characteristics were measured using data from Online Survey Certification and Reporting data, Long-term Care: Facts on Care in the US and NH Compare.

RESULTS

Offer rates were 69% [standard deviation (SD): 28] for short-stay and 56% (SD: 20) for long-stay residents. Show rates were 19% (SD: 21) for short-stay and 17% (SD: 17) for long-stay residents. After adjusting for NH characteristics, compared to 1-star NHs, higher star-rated NHs had higher offer rates. Champions' participation in check-in calls was positively associated with both outcomes for long-stay residents.

CONCLUSIONS/IMPLICATIONS

Lower-quality NHs seem unable to integrate a novel ACP video education program into routine care processes. Ongoing support for and engagement with NH staff to champion the intervention throughout implementation is important for the success of a pragmatic trial within NHs.

Geriatric palliative care: a view of its concept, challenges and strategies

In aging societies, the last phase of people’s lives changes profoundly, challenging traditional care provision in geriatric medicine and palliative care. Both specialties have to collaborate closely and geriatric palliative care (GPC) should be conceptualized as an interdisciplinary field of care and research based on the synergies of the two and an ethics of care.

Major challenges characterizing the emerging field of GPC concern (1) the development of methodologically creative and ethically sound research to promote evidence-based care and teaching; (2) the promotion of responsible care and treatment decision making in the face of multiple complicating factors related to decisional capacity, communication and behavioural problems, extended disease trajectories and complex social contexts; (3) the implementation of coordinated, continuous care despite the increasing fragmentation, sectorization and specialization in health care.

Exemplary strategies to address these challenges are presented: (1) GPC research could be enhanced by specific funding programs, specific patient registries and anticipatory consent procedures; (2) treatment decision making can be significantly improved using advance care planning programs that include adequate decision aids, including those that address proxies of patient who have lost decisional capacity; (3) care coordination and continuity require multiple approaches, such as care transition programs, electronic solutions, and professionals who act as key integrators.

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.

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

CONTEXT

Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record.

OBJECTIVES

The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record.

METHODS

Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes).

RESULTS

The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders.

CONCLUSION

Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.

Feasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE)

BACKGROUND

Geriatric evaluation and management has become standard care for community dwelling older adults following an acute admission to hospital. It is unclear whether this approach is beneficial for the frailest older adults living in permanent residential care. This study was undertaken to evaluate (1) the feasibility and consumer satisfaction with a geriatrician-led supported discharge service for older adults living in residential care facilities (RCF) and (2) its impact on the uptake of Advanced Care Planning (ACP) and acute health care service utilisation.

METHODS

In 2002-4 a randomised controlled trial was conducted in Melbourne, Australia comparing the geriatrician-led outreach service to usual care for RCF residents. Patients were recruited during their acute hospital stay and followed up at the RCF for six months. The intervention group received a post-discharge home visit within 96 hours, at which a comprehensive geriatric assessment was performed and a care plan developed. Participants and their families were also offered further meetings to discuss ACPs and document Advanced Directives (AD). Additional reviews were made available for assessment and management of intercurrent illness within the RCF. Consumer satisfaction was surveyed using a postal questionnaire.

RESULTS

The study included 116 participants (57 intervention and 59 controls) with comparable baseline characteristics. The service was well received by consumers demonstrated by higher satisfaction with care in the intervention group compared to controls (95% versus 58%, p = 0.006).AD were completed by 67% of participants/proxy decision makers in the intervention group compared to 13% of RCF residents prior to service commencement. At six months there was a significant reduction in outpatient visits (intervention 21 (37%) versus controls 45 (76%), (p < 0.001), but no difference in readmissions rates (39% intervention versus 34% control, p = 0.6). There was a trend towards reduced hospital bed-day utilisation (intervention 271 versus controls 372 days).

CONCLUSION

It is feasible to provide a supported discharge service that includes geriatrician assessment and care planning within a RCF. By expanding the service there is the potential for acute health care cost savings by decreasing the demand for outpatient consultation and further reducing acute care bed-days.

Implementing an advance care planning program in German nursing homes: results of an inter-regionally controlled intervention trial

BACKGROUND

Advance Care Planning (ACP) is a systematic approach to ensure that effective advance directives (ADs) are developed and respected. We studied the effects of implementing a regional ACP program in Germany.

METHODS

In a prospective, inter-regionally controlled trial focusing on nursing homes (n/hs), we compared the number, relevance and validity of new ADs completed in the intervention region versus the control region. Intervention n/h residents and their families were offered professional facilitation including standardized documentation.

RESULTS

Data from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months. In the intervention region, 49 (36.0%) participating residents completed a new AD over the period of the study, compared to 18 (4.1%) in the control region; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region. Proxies were designated in 94.7% versus 50.0% of cases, the AD was signed by a physician in 93.9% versus 16.7%, and an emergency order was included in 98.0% versus 44.4%. Resuscitation status was addressed in 95.9% versus 38.9% of cases (p<0.01 for all of the differences mentioned above). In the intervention region, new ADs were preceded by an average of 2.5 facilitated conversations (range, 2–5) with a mean total duration of 100 minutes (range, 60–240 minutes).

CONCLUSION

The implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making. Future research should assess the effect of such programs on clinical and structural outcomes.

Evaluation of the capacity to appoint a healthcare proxy

The appointment of a healthcare proxy is the most common way through which patients appoint a surrogate decision maker in anticipation of a future time in which they may lack the ability to make medical decisions themselves. In some situations, when a patient has not previously appointed a surrogate decision maker through an advance directive, the healthcare team may ask whether the patient, although lacking the capacity to make a healthcare decision, might still have the capacity to appoint a healthcare proxy. In this article the authors summarize the existing, albeit limited, legal and empirical basis for this capacity and propose a model for assessing capacity to appoint a healthcare proxy that incorporates clinical factors in the context of the risks and benefits specific to surrogate appointment under the law. In particular, it is important to weigh patients' understanding and choice within the context of the risks and benefits of the medical and interpersonal factors. Questions to guide capacity assessment are provided for clinical use and refinement through future research.

Medical decision-making for older adults without family

Each year in the United States, individuals who lack decision-making capacity because of acute or chronic cognitive impairment are in situations in which important medical decisions must be made for them, but tens of thousands of these individuals have no known family members or designated surrogates available to help with those decisions. Such individuals constitute 16% of patients in intensive care units, 3% of nursing home residents, and a large but unspecified number of individuals in a variety of settings who are facing end-of-life decisions. Several approaches are currently used to aid in medical decision-making for people without families or designated surrogates, including hospital ethics committees, court-appointed surrogate agents, reliance on advance directives if they are available, and even the use of computer-based decision systems. These approaches all have limitations and often result in individuals receiving care that would not have been their preference. Additionally, because clinical care teams must wrestle with uncertainty about best approaches to care, lengths of hospital stay for individuals without family are longer, resulting in higher healthcare costs and potentially more-aggressive interventions than individuals with family experience. This article reviews medical decision-making for older adults without families or designated surrogates and proposes a solution: "health fiduciaries"--a new type of professional trained and certified to act as a surrogate decision-maker for individuals who are unable to make decisions for themselves.

Advance directives in nursing homes: prevalence, validity, significance, and nursing staff adherence

BACKGROUND

The German Advance Directives Act of 2009 confirms that advance directives (ADs) are binding. Little is known, however, about their prevalence in nursing homes, their quality, and whether they are honored.

METHODS

In 2007, we carried out a cross-sectional survey in all 11 nursing homes of a German city in the state of North Rhine-Westphalia (total nursing home population, 1089 residents). The ADs were formally analyzed and assessed by 3 raters with respect to 5 clinical decision-making scenarios. The specifications of the ADs were compared with what the nurses reported that they would do in each scenario.

RESULTS

11% of the nursing home residents had a personal AD, and a further 1.4% an AD by proxy. 52% of the 119 ADs that we analyzed contained no documentation of the patient's decision-making capacity and/or voluntariness, and only 3% contained documentation of a medical consultation. Most ADs failed to state what should be done in case the patient acutely became incapable of consenting to treatment (inter-rater agreement [IRA] >83%). For the case of permanent decisional incapacity, many ADs contained ambiguous information (IRA<43%). 23 directives stated that the patient should not have cardiopulmonary resuscitation in case an arrest occurred in the patient's current clinical condition, but the nurses reported a corresponding do-not-resuscitate agreement for only 9 of these 23 patients.

CONCLUSION

In 2007, ADs were rare in these German nursing homes, and most of the existing ones were invalid, of little meaning, and/or disregarded by the nursing staff. There is little reason to believe that the Advance Directives Act of 2009 will bring about any major change in this miserable status quo. Advance care planning, a system-oriented concept still uncommon in Germany, could give new impulses to promote a cultural change in this respect.

Improving transitions: efficacy of a transfer form to communicate patients' wishes

The objective of this study was to test the efficacy of a standardized form used during transfers between long-term care facilities (LTCFs) and the acute care setting. The intervention consisted of development and implementation of the transfer form and education about its use. Charts from 26 LTCFs and 1 acute care hospital were reviewed at 1 and 6 months prior to initiation of the transfer form (2007) and at 1 and 6 months after initiation of the transfer form (2008); 210 patient charts were reviewed in 2007 and 172 in 2008. There was 79% concordance between documented LTCF advance directives (ADs) and hospital ADs in 2008-an increase from 66.6% in 2007 (P = .038). Inpatient hospice/palliative care admissions rose from 1.5% in 2007 to 7.7% in 2009 (P = .015). The standardized transfer form improved communication of ADs between LTCFs and the hospital. Secondarily, it may have increased admissions to the acute palliative care unit.

Ethical issues in palliative care

Ethical problems in medicine are common, especially when caring for patients at the end of life. However, many of these issues are not adequately identified in the outpatient setting. Primary care providers are in a unique and privileged position to identify ethical issues, prevent future conflicts, and help patients make medical decisions that are consistent with their individual values and preferences. This article describes some of the more common ethical issues faced by primary care physicians caring for patients with life-limiting illness.

A complex regional intervention to implement advance care planning in one town's nursing homes: Protocol of a controlled inter-regional study

Background

Advance Care Planning (ACP) is an emerging strategy to ensure that well-reflected, meaningful and clearly documented treatment preferences are available and respected when critical decisions about life-sustaining treatment need to be made for patients unable to consent. In Germany, recent legislation confirms that advance directives (AD) have to be followed if they apply to the medical situation, but implementation of ACP has not yet been described.

Methods/Design

In a longitudinal controlled study, we compare 1 intervention region (4 nursing homes [n/hs], altogether 421 residents) with 2 control regions (10 n/hs, altogether 985 residents). Inclusion went from 01.02.09 to 30.06.09, observation lasted until 30.06.10. Primary endpoint is the prevalence of ADs at follow-up, 17 (12) months after the first (last) possible inclusion. Secondary endpoints compare relevance and validity of ADs, process quality, the rate of life-sustaining interventions and, in deceased residents, location of death and intensity of treatment before death. The regional multifaceted intervention on the basis of the US program Respecting Choices^® comprises training of n/h staff as facilitators, training of General Practitioners, education of hospital and ambulance staff, and development of eligible tools, including Physician Orders for Life-Sustaining Treatment in case of Emergency (POLST-E).

Participation data: Of 1406 residents reported to live in the 14 n/hs plus an estimated turnover of 176 residents until the last possible inclusion date, 645 (41%) were willing to participate. Response rates were 38% in the intervention region and 42% in the control region. Non-responder analysis shows an equal distribution of sex and age but a bias towards dependency on nursing care in the responder group. Outcome analysis of this study will become available in the course of 2011.

Discussion

Implementing an ACP program for the n/hs and related health care providers of a region requires a complex community intervention with the effect of nothing less than a cultural shift in this health care sector. This study is to our knowledge the first to develop a strategy for regional implementation of ACP, and to evaluate its feasibility in a controlled design.

Trial Registration

ISRCTN: ISRCTN99887420

The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review

BACKGROUND

Dementia is a progressive and incurable disease which presents many challenges to care providers, particularly in terms of end-of-life care. A palliative approach; that is an approach to care which seeks to ease burdensome symptoms without attempting curative treatment, has been suggested as the most appropriate framework for addressing the needs of these people.

OBJECTIVES

The overall objective was to establish best practice in relation to palliative care for people with advanced dementia in terms of effectiveness and appropriateness.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished English language studies, published between 1997 and 2009. A three-step search strategy was utilised in each component of this review.

CRITICAL APPRAISAL

Quantitative, qualitative and discursive text articles were included in this review. Articles were assessed for congruence to the review criteria and then critically appraised for quality using the appropriate JBI tool.

DATA COLLECTION AND ANALYSIS

Data were extracted using the appropriate JBI data extraction tool for each methodology. No quantitative meta-analysis was possible due to clinical and statistical heterogeneity. Qualitative synthesis was performed with the JBI QARI tool. Discursive textual synthesis was performed with the JBI NOTARI tool.

RESULTS

Quantitative studies recommended the use of do not resuscitate, do not hospitalise orders and other forms of advance directives to prevent interventions unwanted by the patient and/or their family. Feeding tubes and the use of intravenous antibiotics were not found to be an effective intervention. Interventions designed to treat the burdensome symptoms of advanced dementia (such as pain and agitation) were found to be of the most benefit to patients.Qualitative analysis found it distressing for families to discuss or plan for, a poor quality of life for their loved one during the process of dying. Decisions concerned with palliative treatment for the person with advanced dementia were found to be complicated by knowledge differences, lack of understanding of the disease trajectory of dementia, the unpredictable nature of dementia itself and religious and socio-economical issues. Textual analysis found that a palliative approach to end of life care in advanced dementia is both appropriate and effective in terms of benefit to patients and their significant others.Despite the large volume of data retrieved and analysed for this review, no studies examining the role of case-conferencing for managing the introduction of palliative care or managing a palliative approach met the inclusion criteria for this systematic review.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR FUTURE RESEARCH: There is a need for further studies in the area of palliation and advanced dementia, particularly high quality studies investigating palliative care case conferencing and other methods of arranging and planning end of life care for people with dementia.

CONCLUSION

There is some evidence to suggest that a palliative approach is both effective and appropriate for use with people who have advanced dementia. There is no evidence for or against the use of case-conferencing as a method of arranging care for people with advanced dementia.

Effectiveness of end-of-life education among community-dwelling older adults

The purpose of this study was to evaluate the effectiveness of an educational intervention regarding end-of-life discussion directed at older Japanese adults and their attitude to and acceptance of this intervention. A quasi-experimental design was used. A total of 121 older adults, aged 65 years and over, consented to participate. Data from 55 intervention and 57 control participants were used for the analysis. The intervention consisted of an education program comprising a video, a lecture using a handout, and discussion among participants. The control group received only the handout. Both groups were followed up after one month. The intervention group’s attitude became more favorable towards advance directives, especially living wills (P = 0.024). In addition, their expression of preference for life-sustaining treatment by means of artificial nutrition was less at follow up, demonstrating that these older adults had become more autonomous (P = 0.008). There was greater acceptance of the intervention as a whole by the intervention group compared with the control group (P = 0.011). Although few participants overall completed living wills, at follow up twice as many in the intervention group had discussed end-of-life matters with family members and/or their physician.

End of life care for community dwelling older people with dementia: an integrated review

OBJECTIVE

To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes).

DESIGN

An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list.

RESULTS

Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done.

CONCLUSIONS

Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die.

Let someone else decide?

This paper outlines the development of an advance care planning service, in partnership with general practitioners, specialists and facility staff that supports Nursing Home (NH) residents with dementia and their families. The aim of the service is to put a process in place whereby treatment options for residents, who have lost decision-making ability, can be considered in advance of any further episodes of illness. A 10 step plan was developed to implement Advance Care Planning within high level residential aged care facilities. Issues that arose during the course of the project are also discussed. The legal context for substitute decision-making is explained. Issues such as when to have these conversations, how to approach families, are discussed

Attitudes of patients with malignancies towards completion of advance directives

AIM

The purpose of advance directives (AD) is to preserve the patient's autonomy at the end of his/her life. In a cohort study, we investigated attitudes towards AD in hospitalized patients with malignant disease.

MATERIALS AND METHODS

All patients were informed about the basic features of AD in a standardized manner by a single independent physician. One hundred and eight (39 women, 69 men; mean age 56.6 +/- 14.9 years) of 140 invited patients completed the study.

MAIN RESULTS

Five percent of patients (5/108) already had an AD; 85% (92/108) did not wish to issue an AD. "Full confidence in physicians" (22%) and "not important for me at the moment" (15%) were the most frequently stated reasons for not issuing an AD. Only 10% (11/108) of patients decided to complete an AD. Their decision was not related to a specific diagnosis or a number of socio-demographic variables that were studied. Patients who decided in favor of an AD had significantly higher Hospital Anxiety and Depression Scale (HADS-D) score than those who decided against it (HADS-D, 8.3 +/- 5.0 vs.5.8 +/- 4.1, p = 0.035). The patients' HADS depression score was negatively associated with their Karnofsky index (r = -0.232, p = 0.017).

CONCLUSIONS

Our data reveal a scarce demand for AD in our population of hospitalized cancer patients. Patients who wanted to issue an AD had a high HADS-D, which is associated with a low performance status.

Identifying the factors that facilitate or hinder advance planning by persons with dementia

We performed semistructured interviews with 30 family members of patients with advanced dementia to identify the factors that facilitate or hinder advance planning by persons with dementia. All interviews were analyzed using qualitative data analysis techniques. The majority (77%) of family members reported that their relative had some form of written advance directive, and at least half reported previous discussions about health care preferences (57%), living situation or placement issues (50%), and finances or estate planning (60%) with the patient. Family members reported some themes that prompted planning and others that were barriers to planning. Events that most often triggered planning were medical, living situation, or financial issues associated with a friend or family member of the patient (57%). Barriers to planning included both passive and active avoidance. The most common form of passive avoidance was not realizing the importance of planning until it was too late to have the discussion (63%). The most common form of active avoidance was avoiding the discussion (53%). These data suggest potentially remediable strategies to address barriers to advance planning discussions.

Advance care planning and hospital in the nursing home

BACKGROUND

the number of nursing home residents (NHRs) in hospital is increasing although hospital admission may be deleterious to their health.

OBJECTIVE

to evaluate a system of educating residents, their families, staff and general practitioners about outcomes of dementia, advance care planning (ACP) and hospital in the home.

METHODS

we employed one clinical nurse consultant, who utilised the 'Let Me Decide' Advance Care Directive. The intervention area consisted of two hospitals and the 21 nursing homes (NHs) around them compared with another, geographically separate, hospital and the 13 homes around it. We conducted a controlled evaluation monitoring emergency admissions to hospital.

RESULTS

emergency calls to the ambulance service from intervention NHs decreased (intervention versus control; -1 versus +21%; P = 0.0019). The risk of a resident being in an intervention hospital bed for a day compared with in a control hospital bed, per NH bed, fell by a quarter from being initially similar [Relative Risk (RR) = 1.01; 95% confidence interval (CI) 0.98-1.04; P = 0.442] to being lower (RR = 0.74; 95% CI 0.72-0.77; P<0.0001). There was no significant change in mortality in the intervention homes, but in the control homes mortality rose in the third year to be 11.2 per 100 beds higher than in the intervention area (P<0.05).

CONCLUSION

ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs.