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Chua KLM, Chan JQV, Tan LLC, Low JA. Facts to Snacks. Evaluating the Effectiveness of Bite-Sized Animations in Teaching Palliative Care to Medical Students. Am J Hosp Palliat Care 2024:10499091241240053. [PMID: 38520168 DOI: 10.1177/10499091241240053] [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: 03/25/2024] Open
Abstract
BACKGROUND Current palliative care training in medical school is inadequate in preparing doctors to provide quality palliative care. Little attention is paid to determining effective methods of training. OBJECTIVE To assess the use of bite-sized animations in improving the confidence, knowledge and attitudes of medical students towards palliative care. METHODS A mixed methods cohort study was adopted for the study. 50 medical students without prior palliative training completed questionnaires before and after watching a 12-part animated palliative care video series called PowerFacts. Of these participants, 18 underwent semi-structured interviews. RESULTS The quantitative results showed that animations are effective in improving the confidence (P < .001) and knowledge (P < .001), but not the attitudes (P = .183) of medical students. Confidence, knowledge and attitudes were not correlated. Analysis of follow-up interviews of a convenience sample of participants showed that animations can be effective in teaching knowledge and does fill some gaps in palliative education for medical undergraduates. However, the content delivered as a sole learning tool is inadequate in preparing medical students for clinical practice. CONCLUSION All participants achieved level 1 (reaction), some achieved level 2 (learning) but most did not achieve level 3 (behaviour) of the Kirkpatrick's model. There is a need for a multimodal approach in the comprehensive teaching of palliative care in undergraduate medical training to achieve all four levels of the Kirkpatrick Model.
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Affiliation(s)
- Kai Lin Megan Chua
- Lee Kong Chian School Of Medicine, Nanyang Technological University, Singapore
| | - Jin Qi Valerie Chan
- Lee Kong Chian School Of Medicine, Nanyang Technological University, Singapore
| | - Laurence Lean Chin Tan
- GeriCare, Khoo Teck Puat Hospital, Singapore
- Department of Geriatric Medicine and Palliative Care, Khoo Teck Puat Hospital, Singapore
- Department of Knowledge Translation, Geriatric Education and Research Institute (GERI), Singapore
| | - James Alvin Low
- GeriCare, Khoo Teck Puat Hospital, Singapore
- Department of Geriatric Medicine and Palliative Care, Khoo Teck Puat Hospital, Singapore
- Department of Knowledge Translation, Geriatric Education and Research Institute (GERI), Singapore
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Lendon JP, Caffrey C, Lau DT. End-Of-Life Care Planning and Bereavement Practices Among Adult Day Services Centers, 2018. Am J Hosp Palliat Care 2024; 41:262-269. [PMID: 36898004 PMCID: PMC11056790 DOI: 10.1177/10499091231163269] [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: 03/12/2023] Open
Abstract
Introduction: This study describes the end-of-life (EOL) care planning and bereavement practices among adult day services centers (ADSC) when an ADSC participant is dying or has died. Methods: Data are from the 2018 National Study of Long-term Care Providers' biennial survey of ADSCs. Respondents were asked about the following 4 practices: 1) honoring the deceased in some public way in this center; 2) offering bereavement services to staff and participants; 3) documenting in the care plan what is important to the individual at the end of life (EOL), such as the presence of family or religious or cultural practices; and 4) discussing spiritual needs at care planning conferences. ADSC characteristics included US Census region, metropolitan statistical area status, Medicaid authorization, electronic health records (EHR) use, for-profit status, employment of aides, services provision, and model type. Results: About 50% to 30% of ADSCs offered the EOL care planning or bereavement services. Honoring the deceased was the most common practice (53%), followed by bereavement services (37%), discussing spiritual needs (29%), and documenting what is important at EOL (28%). Fewer ADSCs in the West had EOL practices relative to the other regions. The EOL planning and bereavement practices were offered more often in ADSCs that used EHRs, accepted Medicaid, employed an aide, provided nursing, hospice, and palliative care services, and were categorized as medical models, compared with ADSCs without these characteristics. Conclusion: These results highlight the importance of understanding how ADSCs provide EOL and bereavement care to participants who are near EOL.
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Affiliation(s)
| | | | - Denys T Lau
- National Center for Health Statistics, Hyattsville, MD, USA
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3
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Stevenson DG, Ferrell BR, Ersek M. Improving Palliative and End-of-Life Care in Nursing Homes: Time to Renew Our Commitment. J Palliat Med 2022; 25:846-848. [PMID: 35647639 DOI: 10.1089/jpm.2022.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David G Stevenson
- Department of Health Policy, Vanderbilt University School of Medicine, and Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Betty R Ferrell
- Division of Nursing Research and Education, City of Hope, Duarte, California, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Lei L, Lu Y, Gan Q, Hu Z, Luo Y. Awareness and Perceptions of Palliative Care Among the Elderly: A Qualitative Study. J Palliat Care 2022; 37:204-212. [PMID: 35195464 DOI: 10.1177/08258597221082393] [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: 12/15/2022]
Abstract
Objectives: With the rapidly aging population worldwide, the demand for palliative care is increasing. Palliative care publicity and education must be further developed globally, especially for the elderly. It is essential to perform targeted promotion by understanding the awareness and needs of palliative care of the elderly. This study aimed to investigate elderly people's awareness of palliative care and their own views on and needs for palliative care, which could provide a basis for the popularization of palliative care among them. Methods: A total of 20 elderly people were recruited to participate in the semi-structured, and in-depth interviews. Participants were from communities and nursing homes in Chongqing, China. The interview transcripts were coded using the method of thematic analysis. Results: Finally, 4 themes and 10 subthemes were identified, that is: unawareness of the concept of palliative care (never heard of palliative care, confusion between euthanasia and palliative care), motivations for accepting palliative care (personal perspective: less suffering; family perspective: relieving the burden), factors influencing palliative care decision (cost of palliative care, knowledge of palliative care, opinion of decision-making agents), and necessity and preferences for publicizing palliative care (eagerness to know more about palliative care, focusing on policy and charges, preference for Electronic Media Advertising). Conclusions: Palliative care publicity among the elderly is important and necessary. Findings in this study could provide some insights into how to popularize palliative care among the elderly. Considering the preference of the elderly for access to palliative care information, simultaneous publicity through TV and online channels is suggested. Since the elderly would like to choose their doctors and adult children as decision-making agents, more communication between community, health professionals and family is advocated.
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Affiliation(s)
- Lei Lei
- School of Nursing, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Ya Lu
- School of Nursing, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Quanxi Gan
- Southwest University Hospital, Chongqing, P.R. China
| | - Zongping Hu
- The Thirteenth Hospital of Chongqing, Chongqing, P.R. China
| | - Yu Luo
- School of Nursing, Army Medical University (Third Military Medical University), Chongqing, P.R. China
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5
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Cloutier D, Stajduhar KI, Roberts D, Dujela C, Roland K. 'Bare-bones' to 'silver linings': lessons on integrating a palliative approach to care in long-term care in Western Canada. BMC Health Serv Res 2021; 21:610. [PMID: 34183002 PMCID: PMC8238377 DOI: 10.1186/s12913-021-06606-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/02/2021] [Indexed: 01/03/2023] Open
Abstract
Background ‘Whole-person’ palliative approaches to care (PAC) are important for enhancing the quality of life of residents with life-limiting conditions in long-term care (LTC). This research is part of a larger, four province study, the ‘SALTY (Seniors Adding Life to Years)’ project to address quality of care in later life. A Quality Improvement (QI) project to integrate a PAC (PAC-QI) in LTC was implemented in Western Canada in four diverse facilities that varied in terms of ownership, leadership models, bed size and geography. Two palliative ‘link nurses’ were hired for 1 day a week at each site over a two-year time frame to facilitate a PAC and support education and training. This paper evaluates the challenges with embedding the PAC-QI into LTC, from the perspectives of the direct care, or front-line team members. Sixteen focus groups were undertaken with 80 front-line workers who were predominantly RNs/LPNs (n = 25), or Health Care Aides (HCAs; n = 32). A total of 23 other individuals from the ranks of dieticians, social workers, recreation and rehabilitation therapists and activity coordinators also participated. Each focus group was taped and transcribed and thematically analyzed by research team members to develop and consolidate the findings related to challenges with embedding the PAC. Results Thematic analyses revealed that front-line workers are deeply committed to providing high quality PAC, but face challenges related to longstanding conditions in LTC notably, staff shortages, and perceived lack of time for providing compassionate care. The environment is also characterized by diverse views on what a PAC is, and when it should be applied. Our research suggests that integrated, holistic and sustainable PAC depends upon access to adequate resources for education, training for front-line care workers, and supportive leadership. Conclusions The urgent need for integrated PAC models in LTC has been accentuated by the current COVID-19 pandemic. Consequently, it is more imperative than ever before to move forwards with such models in order to promote quality of care and quality of life for residents and families, and to support job satisfaction for essential care workers.
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Affiliation(s)
- Denise Cloutier
- Department of Geography, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada. .,Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.
| | - Kelli I Stajduhar
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.,School of Nursing, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Della Roberts
- Palliative & End of Life Care, Island Health, 1952 Bay Street, Victoria, BC, V8R 1 J8, Canada
| | - Carren Dujela
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Kaitlyn Roland
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.,School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
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6
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Temkin-Greener H, Yan D, Wang S, Cai S. Racial disparity in end-of-life hospitalizations among nursing home residents with dementia. J Am Geriatr Soc 2021; 69:1877-1886. [PMID: 33749844 DOI: 10.1111/jgs.17117] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. DESIGN Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. SETTING Long-stay residents who died in a NH or a hospital within 8 days of discharge. PARTICIPANTS Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. MAIN OUTCOMES AND MEASURES The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. RESULTS Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. CONCLUSIONS AND RELEVANCE We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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7
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Ikeda-Sonoda S, Ichihara N, Okochi J, Takahashi A, Miyata H. Association of care workers' job satisfaction and global happiness with change of functional performance of severely disabled elderly residents in nursing homes: a cohort and questionnaire study in Japan. BMJ Open 2020; 10:e033937. [PMID: 33020074 PMCID: PMC7537441 DOI: 10.1136/bmjopen-2019-033937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES There is growing concern regarding quality of work life (QWL) among care staff in nursing homes. However, little is known about the impact of QWL on nursing home residents' functional performance. Recent literature suggests that job satisfaction and happiness of healthcare workers reflect their perceived QWL and impact the quality of their care. This study examined the association between job satisfaction and global happiness with change in functional performance of severely disabled elderly residents in nursing homes. DESIGN A retrospective cohort study of nursing home residents combined with a questionnaire survey of their care staff. SETTING Eighteen nursing homes in Japan. PARTICIPANTS Data were collected from 1000 residents with a required care level of 3-5 and from 412 care staff in nursing homes between October 2017 and March 2018. OUTCOMES AND EXPLANATORY VARIABLES Functional performance was structurally assessed with ICF (International Classification of Functioning, Disability and Health) staging, composed of 52 items concerning activities of daily life, cognitive function and social participation, at baseline and 6 months later. Deterioration and improvement of functional performance were dichotomously defined as such change in any of the items. QWL of care staff was evaluated with a questionnaire including questions about job satisfaction and global happiness. RESULTS Functional performance deteriorated and improved in 23.0% and 12.7% of residents, respectively. Global happiness of care staff was associated with lower probability of residents' deterioration (adjusted OR, 0.61; CI 0.44 to 0.84). There was no significant correlation between job satisfaction or happiness of care staff and improvement of residents' functional performance. CONCLUSION These results suggest that QWL of care staff is associated with changes in functional performance of elderly people with severe disabilities in nursing homes.
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Affiliation(s)
- Shino Ikeda-Sonoda
- Department of Health Policy and Management, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jiro Okochi
- Geriatric Health Services Facility of Tatsumanosato, Wakakoukai Health Care Corporation, Daito City, Osaka, Japan
| | - Arata Takahashi
- Department of Health Policy and Management, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Tokyo, Japan
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Tark A, Agarwal M, Dick AW, Song J, Stone PW. Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death. Am J Hosp Palliat Care 2020; 38:812-822. [PMID: 32878457 DOI: 10.1177/1049909120956650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.
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Affiliation(s)
- Aluem Tark
- Columbia University School of Nursing, New York, NY, USA.,4083University of Iowa College of Nursing, Iowa City, IA, USA
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY, USA
| | | | - Jiyoun Song
- Columbia University School of Nursing, New York, NY, USA
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Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17145130. [PMID: 32708596 PMCID: PMC7400302 DOI: 10.3390/ijerph17145130] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals. Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed. Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public. Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients’ values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.
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Carpenter JG, Lam K, Ritter AZ, Ersek M. A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes. J Am Med Dir Assoc 2020; 21:583-596.e2. [PMID: 31924556 DOI: 10.1016/j.jamda.2019.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/11/2019] [Accepted: 11/20/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal. OBJECTIVE To examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care-symptom management, and ethical aspects-advance care planning). DESIGN Systematic review. METHODS We searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias. RESULTS We screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution. CONCLUSIONS AND IMPLICATIONS Heterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.
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Affiliation(s)
- Joan G Carpenter
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
| | - Karissa Lam
- University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Ashley Z Ritter
- University of Pennsylvania National Clinician Scholars Program, Philadelphia, PA
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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11
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Toscani F, Finetti S, Giunco F, Basso I, Rosa D, Pettenati F, Bussotti A, Villani D, Gentile S, Boncinelli L, Monti M, Spinsanti S, Piazza M, Charrier L, Di Giulio P. The last week of life of nursing home residents with advanced dementia: a retrospective study. BMC Palliat Care 2019; 18:117. [PMID: 31882007 PMCID: PMC6935223 DOI: 10.1186/s12904-019-0510-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/19/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.
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Affiliation(s)
- Franco Toscani
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Silvia Finetti
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Fabrizio Giunco
- Department of Health and Social Services Polo Lombardia 2, Don Carlo Gnocchi Foundation ONLUS, Via Palazzolo, 21, 20149 Milan, Italy
| | - Ines Basso
- Intensive Care Unit, SS Antonio e Biagio e Cesare Arrigo Hospital, Via Venezia, 16, 15121 Alessandria, Italy
| | - Debora Rosa
- University of Milan, section of Don Carlo Gnocchi Foundation, Via A. Capecelatro, 66, 20148 Milan, Italy
| | - Francesca Pettenati
- Lino Maestroni Foundation, Palliative Medicine Research Institute, via Palestro 1, 26100 Cremona, Italy
| | - Alessandro Bussotti
- Agenzia Continuità Ospedale Territorio, Azienda Ospedaliero- Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Daniele Villani
- Neuro-Rehabilitation and Alzheimer Disease Evaluation Unit, Figlie di San Camillo Hospital, Via F. Filzi , 56, 26100 Cremona, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer Disease Evaluation Unit, Ancelle della Carità Hospital, Via G. Aselli, 14 Cremona, Italy
| | - Lorenzo Boncinelli
- Intensive Care Unit Geriatric, AOU Careggi-Largo Brambilla,3, 50134 Florence, Italy
| | - Massimo Monti
- Geriatric Institute Pio Albergo Trivulzio, via Trivulzio, 15, 20146 Milan, Italy
| | - Sandro Spinsanti
- Istituto Giano, Via Stazzo Quadro 7, 00060 Riano (Rm), Milan, Italy
| | - Massimo Piazza
- Italian Foundation of Leniterapia (FILE), Via San Niccolò, 1, 50125 Florence, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, 10126 Turin, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, 10126 Turin, Italy
- SUPSI, Manno, Switzerland
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Abstract
BACKGROUND End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Rieke Schnakenberg
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Stone PW, Agarwal M, Ye F, Sorbero M, Miller SC, Dick AW. Integration of Palliative Care and Infection Management at the End of Life in U.S. Nursing Homes. J Pain Symptom Manage 2019; 58:408-416.e1. [PMID: 31195078 PMCID: PMC6708746 DOI: 10.1016/j.jpainsymman.2019.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Infections in nursing home (NH) residents are often terminal illnesses. Integration of palliative care (PC) and infection management (IM) is a new concept that can help reduce burdensome treatments and improve quality of care for NH residents at the end of life. OBJECTIVES To develop measures of integration, describe the integration in U.S. NHs, and examine predictors of integration. METHODS A nationally representative sample of NHs was surveyed. An instrument to measure integration was tested using factor analyses. Descriptive analyses of each integration factor were conducted, construct validity was examined using correlations between the integration factors and validated measures of PC and IM, and multivariable linear regression models were developed to identify NH characteristics associated with integration. RESULTS A total of 892 NH surveys were returned (49% response rate), 859 with complete data. Three integration factors were identified: patient involvement in care planning (Involvement), formalized advance care planning (Advance Care Planning), and routine practices of integration (Routine Practices). The highest level of integration in NHs was reported for Involvement (mean (μ) = 73.2, standard error [SE] = 1.57), with lower rates for Advance Care Planning and Routine Practices (respectively, μ = 34.1, SE = 1.05; μ = 31.4, SE = 1.48). Each integration measure was weakly, positively associated with the PC and IM measures (r ≤ 0.25, P ≤ 0.01). There were few associations between NH characteristics and integration. CONCLUSION Integration is a distinct concept that is associated with, but different from, PC and IM. Results serve as a baseline assessment of integration in NHs. Continued refinement of the integration instrument is recommended, as is studying if higher integration leads to better resident outcomes.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA.
| | - Feifei Ye
- RAND Corporation, Pittsburgh, Pennsylvania, USA
| | | | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Bone AE, Evans CJ, Etkind SN, Sleeman KE, Gomes B, Aldridge M, Keep J, Verne J, Higginson IJ. Factors associated with older people's emergency department attendance towards the end of life: a systematic review. Eur J Public Health 2019; 29:67-74. [PMID: 30481305 PMCID: PMC6345149 DOI: 10.1093/eurpub/cky241] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. Methods Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged ≥65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. Results Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio-demographic, illness and service factors, with largest effect sizes for service factors. Conclusions In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research.
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Affiliation(s)
- Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Simon N Etkind
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Barbara Gomes
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, Department of Geriatrics and Palliative Medicine, New York, USA
| | - Jeff Keep
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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15
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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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Abstract
Despite hospital palliative care consultations during which goals of care are discussed in the context of poor prognoses, older adults are admitted to nursing homes for post-acute care where the focus is on rehabilitation. The purpose of this qualitative descriptive study was to describe factors that influence discontinuity between a palliative care consult and nursing home care and explore the potential consequences of this discontinuity. Twelve adults (mean age of 80 years) were enrolled from one community hospital and nursing home in the mid-Atlantic United States. Semi-structured interviews and medical record reviews were used to elicit information about clinical course, care processes, and patient/family preferences at hospital discharge and up to four times after nursing home admission. Data were analyzed using inductive content analysis techniques. Analysis revealed two themes: Inadequate Communication characterized by the lack of information about the palliative care consult after hospital discharge and Prognosis Incongruence evidenced by data demonstrating a discrepancy between hospital prognosis and nursing home care. Ongoing communication between settings to re-address goals of care, prognosis, and symptoms-the central tenets of palliative care-is lacking. Efforts to improve access to comprehensive palliative care delivery after hospitalization and during nursing home transitions are greatly needed.
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18
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Norton SA, Ladwig S, Caprio TV, Quill TE, Temkin-Greener H. Staff Experiences Forming and Sustaining Palliative Care Teams in Nursing Homes. THE GERONTOLOGIST 2018; 58:e218-e225. [DOI: 10.1093/geront/gnx201] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 01/25/2023] Open
Affiliation(s)
| | - Susan Ladwig
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Thomas V Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Timothy E Quill
- Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York
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Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial. Med Care 2017; 56:11-18. [PMID: 29068904 DOI: 10.1097/mlr.0000000000000835] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.
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20
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Lima JC, Miller SC. Palliative Care Consults in U.S. Nursing Homes: Not Just for the Dying. J Palliat Med 2017; 21:188-193. [PMID: 28817348 DOI: 10.1089/jpm.2017.0099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Little is known about nursing home (NH) residents who receive palliative care (PC) consults in the United States. OBJECTIVE Separately by short versus long (≥90 days) stays, to describe NH residents with PC consults compared to a prevalent NH sample. DESIGN Descriptive longitudinal study. SETTING/SUBJECTS NH residents in 2008-2010 in 54 NHs. MEASUREMENTS Resident characteristics came from merged Medicare and NH data from the Centers for Medicare and Medicaid Services and consult information from two PC organizations that were the sole PC consult providers in the study NHs. RESULTS Four percent of all NH residents received a PC consult during the study period. Two-thirds had short NH stays, and 81% of short- and 27% of long-stay consult recipients were on the Medicare skilled nursing facility (SNF) benefit at the time of initial consult. Short- and long-stay NH residents with PC consults differed not only, in many respects, from NH residents generally but also from each other. Despite these differences, half of short-stay and 57% of long-stay residents were alive six months after initial consults. Residents dead at six months died at 33.5 and 34.5 median days (respectively) after initial consults. At six months, 65% of surviving short-stay consult recipients were in the community without hospice, while 59% of long-stay residents were in the NH without hospice or Medicare SNF care. CONCLUSION The high rates of SNF care and six-month survival among NH recipients of PC consults demonstrate the utility of these consults before Medicare hospice eligibility or use.
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Affiliation(s)
- Julie C Lima
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health , Providence, Rhode Island
| | - Susan C Miller
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health , Providence, Rhode Island
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21
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Fosse A, Zuidema S, Boersma F, Malterud K, Schaufel MA, Ruths S. Nursing Home Physicians' Assessments of Barriers and Strategies for End-of-Life Care in Norway and The Netherlands. J Am Med Dir Assoc 2017; 18:713-718. [PMID: 28465128 DOI: 10.1016/j.jamda.2017.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/11/2017] [Accepted: 03/13/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. DESIGN A cross-sectional study using an electronic questionnaire was conducted in 2015. SETTING AND PARTICIPANTS All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). MEASUREMENTS We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ2 test and t-test. RESULTS Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. CONCLUSIONS Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Sytse Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, Groningen, The Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University of Groningen, Groningen, The Netherlands
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Margrethe Aase Schaufel
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabine Ruths
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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22
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van der Plas AG, Oosterveld-Vlug MG, Pasman HRW, Onwuteaka-Philipsen BD. Relating cause of death with place of care and healthcare costs in the last year of life for patients who died from cancer, chronic obstructive pulmonary disease, heart failure and dementia: A descriptive study using registry data. Palliat Med 2017; 31:338-345. [PMID: 28056634 DOI: 10.1177/0269216316685029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The four main diagnostic groups for palliative care provision are cancer, chronic obstructive pulmonary disease, heart failure and dementia. But comparisons of costs and care in the last year of life are mainly directed at cancer versus non-cancer or within cancer patients. AIM Our aim is to compare the care and expenditures in their last year of life for Dutch patients with cancer, chronic obstructive pulmonary disease, heart failure or dementia. DESIGN Data from insurance company Achmea (2009-2010) were linked to information on long-term care at home or in an institution, the National Hospital Registration and Causes of Death-Registry from Statistics Netherlands. For patients who died of cancer ( n = 8658), chronic obstructive pulmonary disease ( n = 1637), heart failure ( n = 1505) or dementia ( n = 3586), frequencies and means were calculated, Lorenz curves were drawn up and logistic regression was used to compare patients with high versus low expenditures. RESULTS For decedents with cancer and chronic obstructive pulmonary disease, the highest costs were for hospital admissions. For decedents with heart failure, the highest costs were for the care home (last 360 days) and hospital admissions (last 30 days). For decedents with dementia, the highest costs were for the nursing home. CONCLUSION Patients with dementia had the highest expenditures due to nursing home care. The number of dementia patients will double by the year 2030, resulting in even higher economic burdens than presently. Policy regarding patients with chronic conditions should be informed by research on expenditures within the context of preferences and needs of patients and carers.
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Affiliation(s)
- Annicka Gm van der Plas
- 1 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,2 Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,3 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Mariska G Oosterveld-Vlug
- 1 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,2 Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,3 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- 1 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,2 Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,3 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- 1 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.,2 Center of Expertise in Palliative Care, VU University Medical Center, Amsterdam, The Netherlands.,3 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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23
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Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings. Contemp Clin Trials 2017; 56:1-8. [PMID: 28315478 DOI: 10.1016/j.cct.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. METHODS/DESIGN This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. DISCUSSION Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.
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Bükki J, Neuhaus PM, Paal P. End of life care in nursing homes: Translating focus group findings into action. Geriatr Nurs 2016; 37:440-445. [DOI: 10.1016/j.gerinurse.2016.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/06/2016] [Accepted: 06/13/2016] [Indexed: 11/30/2022]
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Temkin-Greener H, Li Q, Li Y, Segelman M, Mukamel DB. End-of-Life Care in Nursing Homes: From Care Processes to Quality. J Palliat Med 2016; 19:1304-1311. [PMID: 27529742 DOI: 10.1089/jpm.2016.0093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. DESIGN AND METHODS We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. RESULTS Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice. CONCLUSIONS Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.
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Affiliation(s)
- Helena Temkin-Greener
- 1 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry , Rochester, New York
| | - Qinghua Li
- 2 RTI International, Waltham, Massachusetts
| | - Yue Li
- 1 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry , Rochester, New York
| | | | - Dana B Mukamel
- 3 Department of Medicine, University of California , Irvine, California
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26
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Abstract
Communication with residents and their families is important to ensure that the end-of-life experience is in accordance with resident's wishes. A secondary analysis was conducted to determine: (a) who should communicate with the resident/family about death and dying; (b) when communication should occur around death and dying, obtaining a "DNR" order, and obtaining a hospice referral; and (c) what differences exist in communication about death and dying between Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. Greater than 90% of staff (N=2,191) reported that the physician or social worker should communicate about death and dying with residents/families, but only 53% thought that direct care staff should talk with them. Weighted scores for "When communication should occur about death and dying and obtaining a 'DNR' Order" revealed significantly (p < .01) lower scores for unlicensed staff than RNs and LPNS (i.e., licensed staff), indicating that licensed staff were more likely to initiate conversations on admission or at the care-planning meeting, or when the resident's family requested it. No differences were found between staff on communication about obtaining a hospice referral. The identified gaps in perception about who should be communicating can assist in developing appropriate interventions that need future testing. The potential for training regarding communication strategies and techniques could lead to higher satisfaction with end-of-life care for residents and their families.
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27
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Unroe KT, Cagle JG, Lane KA, Callahan CM, Miller SC. Nursing Home Staff Palliative Care Knowledge and Practices: Results of a Large Survey of Frontline Workers. J Pain Symptom Manage 2015; 50:622-9. [PMID: 26150325 PMCID: PMC4755479 DOI: 10.1016/j.jpainsymman.2015.06.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Deficits in quality end-of-life care for nursing home (NH) residents are well known. Palliative care is promoted as an approach to improve quality. The Palliative Care Survey (PCS) is designed to measure NH staff palliative care knowledge and practice. OBJECTIVES To comparing palliative care knowledge and practices across NH staff roles using the PCS, and to examine relationships between facility characteristics and PCS scores. METHODS The PCS was administered to frontline NH staff-certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), and social workers (SWs)-in 51 facilities in 2012. Descriptive statistics were calculated by job role. Linear mixed effects models were used to identify facility and individual factors associated with palliative care practice and knowledge. RESULTS The analytic sample included 1200 surveys. CNAs had significantly lower practice and knowledge scores compared to LPNs, RNs, and SWs (P < 0.05). LPNs had significantly lower psychological, end-of-life, and total knowledge scores than RNs (P < 0.05 for all). Although knowledge about physical symptoms was uniformly high, end-of-life knowledge was notably low for all staff. A one-point higher facility star rating was significantly associated with a 0.06 increase in family communication score (P = 0.003; 95% CI: 0.02-0.09; SE = 0.02). Higher penetration of hospice in the NH was associated with higher end-of-life knowledge (P = 0.003; parameter estimate = 0.006; 95% CI: 0.002-0.010; SE = 0.002). Sixty-two percent of respondents stated that, with additional training, they would be interested in being leaders in palliative care. CONCLUSION Given observed differences in palliative care practice and knowledge scores by staff training, it appears the PCS is a useful tool to assess NH staff. Low end-of-life knowledge scores represent an important target for quality improvement.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - John G Cagle
- University of Maryland-Baltimore School of Social Work, Baltimore, Maryland, USA
| | - Kathleen A Lane
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Tyler DA, Shield RR, Miller SC. Diffusion of palliative care in nursing homes: lessons from the culture change movement. J Pain Symptom Manage 2015; 49:846-52. [PMID: 25499827 PMCID: PMC4441856 DOI: 10.1016/j.jpainsymman.2014.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 10/16/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022]
Abstract
CONTEXT Studies have found that nursing homes (NHs) that rely heavily on Medicaid funding are less likely to implement innovative approaches to care, such as palliative care (PC) or resident-centered approaches commonly referred to as "culture change" (CC). However, a nationally representative survey we previously conducted found that some high Medicaid facilities have implemented these innovative approaches. OBJECTIVES The purpose of this study was to identify the factors that enable some high Medicaid NHs to implement innovative approaches to care. METHODS We conducted telephone interviews with 16 NH administrators in four categories of facilities: 1) low PC and low CC, 2) low PC and high CC, 3) high PC and low CC, and 4) high PC and high CC. Interviews explored strategies used to overcome barriers to implementation and the resources needed for implementation. RESULTS We had expected to find differences between low and high NHs but instead found differences in NHs' experiences with CC and PC. Since the time of our national survey in 2009-2010, most previously low CC NHs had implemented at least some CC practices; however, we did not find similar changes around PC. Administrators reported numerous ways in which they had received information and assistance from outside entities for implementing CC. This was not the case for PC where administrators reported relying exclusively and heavily on hospices for both their residents' PC needs and information related to PC. CONCLUSION PC advocates could learn much from the CC model in which advocates have used multipronged efforts to institute reform.
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Affiliation(s)
- Denise A Tyler
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA; Health Services Research Program, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA.
| | - Renée R Shield
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Susan C Miller
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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