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Wachterman MW, Smith D, Carpenter JG, Griffin HL, Thorpe J, Feder SL, Hoelter J, Ersek M, Shreve S, Kutney-Lee A. A comparison of end-of-life care quality for Veterans receiving hospice in VA nursing homes and community nursing homes. J Am Geriatr Soc 2024; 72:59-68. [PMID: 37947240 PMCID: PMC10842969 DOI: 10.1111/jgs.18606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND While the Veterans Health Administration (VA) has long provided hospice care within VA community living centers (CLCs, i.e., VA nursing homes), an increasing number of Veterans are receiving hospice in VA-contracted community nursing homes (CNHs). However, little data exist about the quality of end-of-life (EOL) care provided in CNHs. The aim of this study was to compare family ratings of the quality of EOL care provided to Veterans receiving hospice in VA CLCs and VA-contracted CNHs. METHODS We conducted a retrospective analysis of national data from VA's electronic medical record and Bereaved Family Survey (BFS) for Veterans who received hospice in VA CLCs or VA-contracted CNHs between October 2021 and March 2022. The final sample included 1238 Veterans who died in either a CLC (n = 1012) or a CNH (n = 226) and whose next-of-kin completed the BFS. Our primary outcome was the BFS global rating of care received in the last 30 days of life. Secondary outcomes included BFS items related to symptom management, communication, emotional and spiritual support, and information about burial and survivor benefits. We compared unadjusted and adjusted proportions for all BFS outcomes between those who received hospice in CLCs and CNHs. RESULTS The adjusted proportion of family members who gave the best possible rating (a score of 9 or 10 out of a possible 10) for the overall care received near EOL was more than 13 percentage points higher for Veterans who received hospice in VA CLCs compared to VA-contracted CNHs. Our findings also revealed quality gaps of even greater magnitude in specific EOL care-focused domains. CONCLUSIONS Our findings document inadequacies in the quality of multiple aspects of EOL care provided to Veterans in CNH-based hospice and illuminate the urgent need for policy and practice interventions to improve this care.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joan G Carpenter
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Hillary L Griffin
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA
- University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Shelli L Feder
- Yale University School of Nursing, Orange, Connecticut, USA
- Pain Research, Informatics, Multi-Morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Jillian Hoelter
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Scott Shreve
- US Department of Veteran Affairs, Hospice and Palliative Care Program, Washington, DC, USA
- Lebanon VA Medical Center, Lebanon, Pennsylvania, USA
| | - Ann Kutney-Lee
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Registered Nurses’ Experiences of End-of-Life Care in Nursing Homes of South Korea: A Qualitative Study. Healthcare (Basel) 2022; 10:healthcare10112213. [PMID: 36360554 PMCID: PMC9690043 DOI: 10.3390/healthcare10112213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to qualitatively describe how registered nurses (RNs) experienced and perceived end-of-life (EOL) care for older residents in South Korean nursing homes. The participants included 11 nurses with experience of providing EOL care for older residents in six nursing homes. Data were collected through one-on-one in-depth interviews using semi-structured questions from 27 December 2019 to 22 October 2020. Around 1–2 interviews were conducted for each participant, and each interview lasted between 40 min and two hours. The interview data were analyzed using qualitative content analysis. Eight sub-themes were identified and abstracted under three themes: (a) “feeling fulfilled for doing my best until the last day,” (b) “defensive coping due to legal and institutional limitations,” and (c) “requirements for effective EOL care.” This study suggests that there are many challenges and issues regarding EOL care at nursing homes. In order to provide effective EOL care to older residents, the foundation of the EOL care system, as well as skills training, should be strengthened. Furthermore, securing qualified nursing manpower and achieving institutional improvement by reducing obstacles are warranted.
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Blankart CR, van Gool K, Papanicolas I, Bernal‐Delgado E, Bowden N, Estupiñán‐Romero F, Gauld R, Knight H, Abiona O, Riley K, Schoenfeld AJ, Shatrov K, Wodchis WP, Figueroa JF. International comparison of spending and utilization at the end of life for hip fracture patients. Health Serv Res 2021; 56 Suppl 3:1370-1382. [PMID: 34490633 PMCID: PMC8579204 DOI: 10.1111/1475-6773.13734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. DATA SOURCES Individual-level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). STUDY DESIGN We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age- and sex-specific effects within and across countries. In addition, we analyzed hospital-centricity, that is, the days spent in hospital and site of death. DATA COLLECTION/EXTRACTION METHODS We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. PRINCIPAL FINDINGS Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. CONCLUSIONS Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.
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Affiliation(s)
- Carl Rudolf Blankart
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- Hamburg Center for Health EconomicsUniversität HamburgHamburgGermany
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Irene Papanicolas
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of Health PolicyLondon School of EconomicsLondonUK
| | | | - Nicholas Bowden
- Department of Women's and Children's HealthUniversity of OtagoDunedinNew Zealand
| | | | - Robin Gauld
- Otago Business School and Centre for Health Systems and TechnologyUniversity of OtagoDunedinNew Zealand
| | | | - Olukorede Abiona
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Kristen Riley
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Andrew J. Schoenfeld
- Division of Orthopedic SurgeryBrigham & Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Kosta Shatrov
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
| | - Walter P. Wodchis
- Institute of Health Policy Management & EvaluationUniversity of TorontoTorontoOntarioCanada
- Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
| | - Jose F. Figueroa
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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Orth J, Li Y, Simning A, Zimmerman S, Temkin-Greener H. Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture. THE GERONTOLOGIST 2021; 61:1296-1306. [PMID: 33206175 PMCID: PMC8809190 DOI: 10.1093/geront/gnaa188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia. RESEARCH DESIGN AND METHODS Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death. RESULTS Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements. DISCUSSION AND IMPLICATIONS Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.
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Affiliation(s)
- Jessica Orth
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research and The Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
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Lamppu PJ, Laakkonen ML, Finne-Soveri H, Kautiainen H, Laurila JV, Pitkälä KH. Training Staff in Long-Term Care Facilities-Effects on Residents' Symptoms, Psychological Well-Being, and Proxy Satisfaction. J Pain Symptom Manage 2021; 62:e4-e12. [PMID: 33794303 DOI: 10.1016/j.jpainsymman.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/15/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Long-term care facility (LTCF) residents have unmet needs in end-of-life and symptom care. OBJECTIVES This study examines the effects of an end-of-life care staff training intervention on LTCF residents' pain, symptoms, and psychological well-being and their proxies' satisfaction with care. METHODS We report findings from a single-blind, cluster randomized controlled trial featuring 324 residents with end-of-life care needs in 20 LTCF wards in Helsinki. The training intervention included four 4-hour educational workshops on palliative care principles (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff in small groups. Education was based on constructive learning methods and included participants' own resident cases, role-plays, and small-group discussions. During a 12-month follow-up we assessed residents' symptoms with the Edmonton Symptom Assessment Scale (ESAS), pain with the PAINAD instrument and psychological well-being using a PWB questionnaire. Proxies' satisfaction with care was assessed using the SWC-EOLD. RESULTS The change in ESAS symptom scores from baseline to 6 months favored the intervention group compared with the control group. However, the finding was diluted at 12 months. PAINAD, PWB, and SWC-EOLD scores remained unaffected by the intervention. All follow-up analyses were adjusted for age, gender, do-not-resuscitate order, need for help, and clustering. CONCLUSION Our rigorous randomized controlled trial on palliative care training intervention demonstrated mild effects on residents' symptoms and no robust effects on psychological well-being or on proxies' satisfaction with care.
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Affiliation(s)
- Pauli J Lamppu
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Helsinki Hospital, Geriatric Clinic, Helsinki, Finland.
| | - Marja-Liisa Laakkonen
- Department of Social Services and Health Care, Helsinki Hospital, Geriatric Clinic, Helsinki, Finland
| | | | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Jouko V Laurila
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Kaisu H Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
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Liu WM, Koerner J, Lam L, Johnston N, Samara J, Chapman M, Forbat L. Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia. J Am Geriatr Soc 2019; 68:305-312. [PMID: 31681981 DOI: 10.1111/jgs.16192] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying. DESIGN Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325. SETTING Twelve Australian care homes in Canberra, Australia. PARTICIPANTS A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018. INTERVENTION Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning. MEASUREMENTS This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney. RESULTS Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72). CONCLUSION The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.
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Affiliation(s)
- Wai-Man Liu
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jane Koerner
- University of Canberra, Canberra, Australian Capital Territory, Australia
| | | | - Nikki Johnston
- Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Juliane Samara
- Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Michael Chapman
- Australian National University, Canberra, Australian Capital Territory, Australia.,ACT Health, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Liz Forbat
- Australian Catholic University, Canberra, Australian Capital Territory, Australia.,University of Stirling, Stirling, United Kingdom
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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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Mohlman WL, Dassel K, Supiano KP, Caserta M. End-of-Life Education and Discussions With Assisted Living Certified Nursing Assistants. J Gerontol Nurs 2018; 44:41-48. [DOI: 10.3928/00989134-20180327-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/05/2018] [Indexed: 01/15/2023]
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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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11
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Noh H. Areas of Control Desired by Patients and Families Referred to Hospice Care: Perspectives of Hospice Admissions Staff. J Appl Gerontol 2017; 38:656-672. [PMID: 28506145 DOI: 10.1177/0733464817709531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Sense of control in end-of-life (EOL) care plays a critical role in the patient's well-being. However, little is known about the areas of control essential to patients and families at a specific time point in the illness trajectory: when patients stop curative treatments and are referred to hospice. This study qualitatively explored such areas. Sixteen admissions staff members from four hospice agencies were interviewed about their perceptions of areas in which patients and families worried about losing control by accepting hospice. The thematic analysis revealed four areas of control: changes to medical care, health care provider changes, use of life-sustaining treatments, and daily life. Participants of this study put a great emphasis on consistently communicating their willingness to honor patients' and families' control over their care decisions and lives. Future research should examine control in EOL care among diverse populations and effectiveness of hospice staff's strategies to address desire for control.
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Affiliation(s)
- Hyunjin Noh
- 1 The University of Alabama, School of Social Work, Tuscaloosa, USA
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12
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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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