Improving the Quality of End-of-Life Care in Long-Term Care Institutions

"I couldn't say goodbye": Thematic analysis of interviews with bereaved relatives who lost their loved ones during the COVID-19 pandemic

BACKGROUND

Delivering serious news is usually challenging for healthcare professionals and the pandemic of COVID-19 and related restrictions brought additional challenges in this process.

AIMS

To explore the experience of bereaved relatives with receiving serious news from healthcare professionals during the pandemic COVID-19.

DESIGN

A qualitative study using thematic analysis and a codebook approach of data collected in semi-structured interviews with bereaved relatives.

SETTING/PARTICIPANTS

Data were collected from July to August 2022 in person/via phone with bereaved relatives who lost their relatives during the pandemic (from March 2020 to March 2022). Participants were recruited using a convenience sample and snowball method through social media and through one university hospital palliative care unit that invited bereaved relatives of deceased patients treated at the unit to participate in this study.

RESULTS

A total of 22 participants, consisting of 4 men and 18 women, were interviewed for this study. Most of the participants were sons or daughters of individuals who had died (5 grandchildren, 14 sons/daughters, 2 spouses, 1 great-niece). Six themes were identified: Burden caused by visit ban, Fear of COVID-19, Inappropriate behaviour and communication of healthcare professionals, High need for emotional support, Need for detailed and honest communication, Tendency to make excuses for mistakes and lapses by healthcare professionals.

CONCLUSIONS

Delivering serious news during a pandemic was negatively influenced by a lack of contact with patients and a lack of support and empathetic communication with staff. Overcoming these circumstances can be achieved by frequent communication using various communication tools (such as videoconferences or phone calls), and maintaining empathy and honesty in the communication process.

Initiatives Targeting Health Care Professionals: A Systematic Review of Knowledge Translation Pain Assessment and Management Studies Focusing on Older Adults

OBJECTIVES

Pain is often undertreated in older adult populations due to factors, such as insufficient continuing education and health care resources. Initiatives to increase knowledge about pain assessment and management are crucial for the incorporation of research evidence into practice. Knowledge translation (KT) studies on pain management for older adults and relevant knowledge users have been conducted; however, the wide variety of KT program formats and outcomes underscores a need to evaluate and systematically report on the relevant literature.

MATERIALS AND METHODS

Using a systematic review methodology, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycInfo, and Web of Science databases were searched from inception to June 2023. Pain-related KT programs targeted towards older adults, their informal caregivers, and health care professionals were examined. Initiatives focusing on health care professionals are the focus of this review. Initiatives focusing on older adults are reported in a companion article.

RESULTS

From an initial 21,669 search results, 172 studies met our inclusion criteria. These studies varied widely in focus and delivery format but the majority were associated with significant risk of bias. In this report, we are focusing on 124 studies targeting health care professionals; 48 studies involving initiatives targeting older adults are reported in a companion article. Moreover, most programs were classified as knowledge mobilization studies without an implementation component. Across all studies, knowledge user satisfaction with the initiative and the suitability of the material presented were most commonly assessed. Patient outcomes, however, were underemphasized in the literature.

CONCLUSION

Patient and clinical outcomes must be a focus of future research to fully conceptualize the success of KT programs for older adult individuals. Without implementation plans, disseminated knowledge does not tend to translate effectively into practice.

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Purpose

Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death.

Patients and Methods

A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal.

Results

Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death.

Conclusion

This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

Association between prognostic awareness and quality of life in patients with advanced cancer

PURPOSE

Despite the current guidelines supporting open communication about serious news, the evidence about the impact of prognostic awareness on the quality of life in cancer patients is not clear. The aim of this study was to assess the association between quality of life and prognostic awareness in patients with advanced cancer.

METHODS

This was a cross-sectional study which involved patients (n = 129) with incurable advanced cancer (estimated by oncologist using 12-month surprise question). Data were collected at oncology departments at 3 hospitals using structured interview in which patients were asked about their quality of life (using Integrated Palliative Outcome Scale-IPOS and a single-item global measure), prognostic awareness, information needs and demographics.

RESULTS

Only 16% of the sample was completely aware of prognosis and 57% was partially aware. Accurate prognostic awareness was significantly associated (p = 0.02) with lower level of quality of life between (when measured by both the IPOS and the single-item scale) patients with accurate prognostic awareness (M = 37.1; 10.4) and partially aware (M = 31.9; 9.1) and unaware patients (M = 30; 7.4). Detailed analysis showed that significant difference between groups was found only for physical symptoms subscales (p = 0.002), not for emotional and communication subscales.

CONCLUSION

Prognostic awareness was found to be negatively associated with physical domain of quality of life, but not with emotional and communication domains. More research is needed on personality factors that might influence the development of prognostic awareness and quality of life.

Improving End-of-Life Care for People with Dementia in LTC Homes During the COVID-19 Pandemic and Beyond

COVID-19 pandemic has resulted in a significant increase in deaths in long-term care homes (LTCH). People with dementia living in LTCHs represent one of the most frail and marginalized populations in Canada. The surge of COVID-19 cases in LTCHs and rationing of health-care resources during the pandemic have amplified the pre-existing need for improvements in palliative and end-of-life care in LTCHs. This position statement, created by a task force commissioned by the Alzheimer Society of Canada, provides recommendations for a multipronged coordinated approach to improving palliative and end-of-life care of people with dementia living in LTCHs during the COVID-19 pandemic and beyond.

The experience of palliative care among older Chinese people in nursing homes: A scoping review

OBJECTIVE

To identify the gaps in understanding the experience of older Chinese people receiving palliative care in nursing homes.

DESIGN

A nine-step scoping review methodology was used to search for relevant literature.

METHODS

Sixteen databases were searched for relevant studies published in English from January 1990 to August 2019. The grey literature was searched for relevant theses pertaining to the topic.

RESULTS

A total of 18 studies from the United States (n = 2), mainland China (n = 1), Hong Kong (n = 13), Taiwan (n = 2) and one thesis from Hong Kong were included in the final analysis. The findings were categorised into four themes: (1) advance care planning preferences; (2) decision-making process related to palliative care; (3) palliative care experiences and barriers; and (4) practice to improve palliative care.

CONCLUSIONS

Given the distinctive experiences of older Chinese residents in nursing homes when faced with death and dying, cultural beliefs strongly influenced their attitudes and behaviours in receiving end-of-life care. As Chinese immigrants have become a major ethnic group in western countries, there is benefit in recognising that older Chinese people living in nursing homes and needing palliative care will face specific challenges. Culturally appropriate interventions to address older Chinese people's existential stress, grief related to loss, communication and dietary requirements, and other barriers should be developed and implemented.

Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature

BACKGROUND

Given the increase in the number of deaths within long-term care facilities (LTCFs), the need for palliative and end-of-life (EOL) care education among such facilities has been increasing. As such, a systematic synthesis of global palliative and EOL care educational approaches and evaluation can aid further educational development.

OBJECTIVE

To synthesise the current literature on palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to, and facilitators of, intervention implementation.

METHODS

The study used an integrative review framework wherein indexed databases, namely, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, Cochrane Library and Japan Medical Abstract Society, were systematically searched for studies published in English and Japanese between 2007 and 2019. Search terms that are related to palliative care, LTCF, and education were combined to increase search sensitivity. The quality of the papers was assessed using Joanna Briggs Institute Critical Appraisal Tools and the Mixed-Methods Appraisal Tool.

RESULTS

A total of 52 studies were included in the review. Our results suggested that although studies in this area and setting have been evolving, suboptimal developmental research and educational practices, global variability and unstandardised approaches to education and lacking viewpoints from service users have remained. Barriers to intervention implementation were also reported due to the specific characteristics of LTCFs, which include high staff turnover and considerable variation in professional skills and experience.

CONCLUSIONS

Given the different LTCF types, systems and policies across each country or region, further research on standardised educational interventions with contextual considerations using large-scale studies with robust methodology is needed to meet the increasing demand for palliative and EOL care among the global ageing population.

IMPLICATIONS FOR PRACTICE

Palliative and EOL care educational intervention for LTCF staff need to include more consideration of context, organisational culture and the user involvement throughout the process of education and research to enhance the quality of care in this complex setting.

Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review

BACKGROUND

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests.

OBJECTIVE

This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol.

METHODS

PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed.

RESULTS

8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology.

CONCLUSION

There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

Barriers and facilitators to palliative care education in nursing and residential homes: a rapid review

BACKGROUND

There is insufficient high-quality evidence to suggest that palliative care education can impact care home settings.

AIMS

To identify, appraise and synthesise all available evidence on the barriers and facilitators to providing palliative care education in residential and nursing care homes and to generate recommendations to increase the effectiveness of future palliative care education programmes in care homes.

METHODS

A rapid review searching CINAHL, Medline and ProQuest. One author screened full-text articles for inclusion. Any uncertainties were discussed with a second author.

FINDINGS

Twenty-two articles were included in the full review. Analysis of the included articles revealed the following overlapping themes: structural systems; cultural and personal issues; and knowledge translation issues with interaction.

CONCLUSION

Addressing the barriers and facilitators when designing palliative care education programmes for care homes will lead to more successful outcomes.

Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities

BACKGROUND

To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial.

OBJECTIVE

This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS).

DESIGN

A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong.

SETTING/SUBJECTS

A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation.

MEASUREMENTS

The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression.

RESULTS

The IRD scale was a strong predictor of mortality in both Sample 1 (HR_sample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HR_sample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively.

CONCLUSIONS

The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.

Education and training to enhance end-of-life care for nursing home staff: a systematic literature review

Background

The delivery of end-of-life care in nursing homes is challenging. This situation is of concern as 20% of the population die in this setting. Commonly reported reasons include limited access to medical care, inadequate clinical leadership and poor communication between nursing home and medical staff. Education for nursing home staff is suggested as the most important way of overcoming these obstacles.

Objectives

To identify educational interventions to enhance end-of-life care for nursing home staff and to identify types of study designs and outcomes to indicate success and benchmark interventions against recent international guidelines for education for palliative and end-of-life care.

Design

Thirteen databases and reference lists of key journals were searched from the inception of each up to September 2014. Included studies were appraised for quality and data were synthesised thematically.

Results

Twenty-one studies were reviewed. Methodological quality was poor. Education was not of a standard that could be expected to alter clinical behaviour and was evaluated mainly from the perspectives of staff: self-reported increase in knowledge, skills and confidence delivering care rather than direct evidence of impact on clinical practice and patient outcomes. Follow-up was often short term, and despite sound economic arguments for delivering effective end-of-life care to reduce burden on the health service, no economic analyses were reported.

Conclusions

There is a clear and urgent need to design educational interventions that have the potential to improve end-of-life care in nursing homes. Robust evaluation of these interventions should include impact on residents, families and staff and include economic analysis.

Improving quality of care and reducing unnecessary hospital admissions: a literature review

As the UK population lives to older ages, with more complex health and social care needs, there comes a time when going to live in a care home might be essential for a frail, older person. Residents and their families expect high-quality care in return for the costs of their placements, but often find this is not the case ( Help the Aged, 2006 ). In order to improve quality in care homes, the Lincolnshire Community Health Services NHS Trust are piloting a care home support team. The new service aims to provide education and training to an unpredictable workforce, with the addition of regular ward rounds in care homes to ensure more proactive care for residents, in order to reduce unnecessary hospital admissions and improve the quality of care offered. This article looks at the literature relating to education and training for staff in care homes to support this service. It also aims to use the reviewed articles to identify specific training and education needed to improve quality of care for residents and reduce avoidable hospital admissions.

End-of-life care research in Hong Kong: A systematic review of peer-reviewed publications

Objective:

This systematic review aimed to examine end-of-life (EoL) care research undertaken in an Eastern cultural context—Hong Kong—with the hope of better informing EoL care professionals and policy makers and providing lessons for other countries or areas that share similar EoL care challenges.

Method:

Eight databases were searched from their respective inception through to August of 2014. All of the resulting studies conducted in Hong Kong and relevant to EoL care or palliative care were examined. The included studies were assessed with respect to study design, care settings, participants, research themes, and major findings.

Results:

Some 107 publications published between 1991 and 2014 were identified. These studies were undertaken at a range of places by different professionals. Of the total, 44 were led by physicians, 36 by nurses, 17 by social workers, and 10 by other professionals. Participants included both inpatients and outpatients with different illnesses, nursing home residents, older community-dwelling adults, deceased individuals, care staff, and informal caregivers. A total of 13 research themes were identified: (1) attitudes to or perceptions of death and dying; (2) utilization of healthcare services, (3) physical symptoms or medical problems; (4) death anxiety or mental health issues; (5) quality of life; (6) advance directives or advance care planning; (7) supportive care needs, (8) decision making; (9) spirituality; (10) cost-effectiveness or utility studies; (11) care professionals' education and training; (12) informal caregivers' perceptions and experience; and (13) scale development or validation.

Significance of results:

While there has been a wide and diverse range of research activities in Hong Kong, EoL care services at primary care settings should be strengthened. Some priority areas for further research are recommended.