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Davies R, Booker M, Ives J, Huntley A. How do primary care clinicians approach hospital admission decisions for people in the final year of life? A systematic review and narrative synthesis. Palliat Med 2024; 38:806-817. [PMID: 39177080 PMCID: PMC11447985 DOI: 10.1177/02692163241269671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The final year of life is often associated with increasing health complexities and use of health services. This frequently includes admission to an acute hospital which may or may not convey overall benefit. This uncertainty makes decisions regarding admission complex for clinicians. There is evidence of much variation in approaches to admission. AIMS To explore how Primary Care clinicians approach hospitalisation decisions for people in the final year of life. DESIGN Systematic literature review and narrative synthesis. DATA SOURCES We searched the following databases from inception to April 2023: CINAHL, Cochrane Library, Embase, MedLine, PsychInfo and Web of Science followed by reference and forward citation reviews of included records. RESULTS A total of 18 studies were included: 14 qualitative, 3 quantitative and 1 mixed methods study. As most of the results were qualitative, we performed a thematic analysis with narrative synthesis. Six key themes were identified: navigating the views of other stakeholders; clinician attributes; clinician interpretation of events; the perceived adequacy of the current setting and the alternatives; system factors and continuity of care. CONCLUSION This review shows that a breadth of factors influence hospitalisation decisions. The views of other stakeholders take great importance but it is not clear how these views are, or should be, should be balanced. Clinician factors, such as experience with palliative care and clinical judgement, are also important. Future research should focus on how different aspects of the decision are balanced and to consider if, and how, this could be improved to optimise patient-centred outcomes and use of health resources.
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Affiliation(s)
- Rachel Davies
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol Medical School, Bristol, UK
| | - Alyson Huntley
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
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2
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DeGraves BS, Meijers JMM, Estabrooks CA, Verbeek H. Palliative care in small-scale living facilities: a scoping review. BMC Geriatr 2024; 24:700. [PMID: 39182044 PMCID: PMC11344427 DOI: 10.1186/s12877-024-05259-9] [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: 03/26/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Innovative small-scale facilities for dementia focus on providing quality of life and maintaining the functional abilities of residents while offering residents a home for life. To fulfill the home-for-life principle, palliative care approaches are necessary to maintain quality of life in these facilities. Few studies have reported on how palliative care is provided to residents in small-scale facilities. The aim of our review is to determine the extent to which palliative care approaches are reported in small-scale facilities. METHODS A scoping review of the literature using recommended methods from the Joanna Briggs Institute. Four databases, CINAHL, PubMed, PsycINFO, and Web of Science, were searched for studies published from 1995 to 2023. One reviewer completed the title, abstract and full-text screening and data extraction; two additional team members piloted the screening and extraction process and met with the main reviewer to make decisions about article inclusion and ensure consistency and accuracy in the review process. The extracted data was open-coded and analyzed using thematic analysis. The data was then synthesized into themes using palliative care domains for dementia. RESULTS Of the 800 articles obtained in the search, only ten met the inclusion criteria: six from Japan, two from the Netherlands, and one each from Austria and the United States. In most small-scale facilities, palliative care is important, with facilities prioritizing family involvement and person-centred care, minimizing resident discomfort and enhancing residents' remaining abilities until the end of life. The included studies did not discuss palliative care policies or professional staff training in depth. CONCLUSIONS This study provides an overview of the literature on palliative care in small-scale facilities for individuals with dementia. Most facilities focus on residents' wishes at the end of life to enhance comfort and provide a home-like environment. However, more research is needed to further understand the quality of palliative care approaches in these homes.
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Affiliation(s)
| | - Judith M M Meijers
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands.
- Living Lab in Ageing and Long-Term Care, Maastricht, Netherlands.
| | | | - Hilde Verbeek
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, Netherlands
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3
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Hormazábal-Salgado R, Osman AD, Poblete-Troncoso M, Whitehead D, Hills D. Advanced Care Directives in Residential Aged Care for Residents with Major Neuro-Cognitive Disorders (Dementia): A Scoping Review. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024; 20:83-114. [PMID: 37382889 DOI: 10.1080/15524256.2023.2229041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The aim of this review was to identify, assess, collate, and analyze existing research that has made a direct contribution to aiding understanding of the ethical and decision-making issues related to the use of advance care directives for people with dementia and/or other major neurocognitive disorders and/or their surrogate decision-makers on treatment. The Web of Science, Scopus, PubMed, CINAHL, Academic Search Ultimate, and MEDLINE databases were searched between August and September 2021 and July to November 2022 limited to primary studies written in English, Spanish, or Portuguese. Twenty-eight studies of varying quality that addressed related thematic areas were identified. These themes being support for autonomy in basic needs (16%), making decisions ahead/planning ahead and upholding these decisions (52%), and support in decision-making for carers (32%). Advance care directives are an important mechanism for documenting treatment preferences in patient care planning. However, the available literature on the topic is limited in both quantity and quality. Recommendations for practice include involving decision makers, promoting educational interventions, exploring how they are used and implemented, and promoting the active involvement of social workers within the healthcare team.
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Affiliation(s)
| | - Abdi D Osman
- College of Sports, Health and Engineering, Victoria University, Melbourne, Australia
| | | | - Dean Whitehead
- Institute of Health and Wellbeing, Federation University Australia, Berwick, Australia
| | - Danny Hills
- Institute of Health and Wellbeing, Federation University Australia, Berwick, Australia
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4
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Guo W, Cai S, Caprio T, Schwartz L, Temkin-Greener H. End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations. J Am Med Dir Assoc 2023; 24:827-832.e3. [PMID: 36913979 PMCID: PMC10238640 DOI: 10.1016/j.jamda.2023.02.002] [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: 08/29/2022] [Revised: 12/19/2022] [Accepted: 02/03/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. DESIGN Cohort study. SETTING AND PARTICIPANTS Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). METHODS We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. RESULTS End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death. CONCLUSIONS AND IMPLICATIONS There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.
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Affiliation(s)
- Wenhan Guo
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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5
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McCarthy EP, Lopez RP, Hendricksen M, Mazor KM, Roach A, Rogers AH, Epps F, Johnson KS, Akunor H, Mitchell SL. Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study. J Am Geriatr Soc 2023; 71:1759-1772. [PMID: 36856071 PMCID: PMC10258152 DOI: 10.1111/jgs.18303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/08/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood. MATERIALS AND METHODS Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021. RESULTS Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race. CONCLUSIONS This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruth Palan Lopez
- School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, Massachusetts, USA
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ashley Roach
- School of Nursing, Oregon Health & Science University, Portland, Oregon, USA
| | - Anita Hendrix Rogers
- Department of Nursing, The University of Tennessee at Martin, Martin, Tennessee, USA
| | - Fayron Epps
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina, USA
- Geriatrics Research Education and Clinical Center, Veteran Affairs Medicine Center, Durham, North Carolina, USA
| | - Harriet Akunor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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6
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Bartley MM, Manggaard JM, Fischer KM, Holland DE, Takahashi PY. Dementia Care in the Last Year of Life: Experiences in a Community Practice and in Skilled Nursing Facilities. J Palliat Care 2023; 38:135-142. [PMID: 36148476 PMCID: PMC10026163 DOI: 10.1177/08258597221125607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). METHODS A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. RESULTS Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs (P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group (P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs (P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs (P = .67). CONCLUSIONS Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.
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Affiliation(s)
- Mairead M Bartley
- Division of Community Internal Medicine, 384842Mayo Clinic, Rochester, MN, USA
| | | | - Karen M Fischer
- Division of Clinical Trials and Biostatistics, 384842Mayo Clinic, Rochester, MN, USA
| | - Diane E Holland
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 384842Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, 384842Mayo Clinic, Rochester, MN, USA
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7
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Huijten DCM, Bolt SR, Meesterberends E, Meijers JMM. Nurses' support needs in providing high-quality palliative care to persons with dementia in the hospital setting: A cross-sectional survey study. J Nurs Scholarsh 2023; 55:405-412. [PMID: 36218182 DOI: 10.1111/jnu.12828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 07/18/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Since dementia is an irreversible progressive disease characterized by a decline in mental functions and overall health, a palliative care approach is recommended. Nevertheless, many persons with dementia experience burdensome hospitalizations in end-of-life care. Their quality of life during hospitalization can be improved by palliative nursing care that suits their fragile health. AIM To explore hospital nurses' perceived support needs while providing high-quality palliative care for persons with dementia and to identify differences between nurses in different ward types and at different educational levels. DESIGN Cross-sectional, multicenter survey study. METHOD Between January 2021 and April 2021, a convenience sample of Dutch hospital nurses received a web-based questionnaire on the topics of palliative caregiving, communication, collaboration, and hospital admissions. The data were analyzed using descriptive statistics. RESULTS The survey was completed by 235 nurses. The most frequently endorsed support needs were "communicating with persons with severe dementia" (58.3%), "appointing a permanent contact person in the care for persons with dementia" (53.6%), and "dealing with family disagreement in end-of-life care" (53.2%). If nurses had more time to provide care, 66.4% of them would prioritize providing personal attention. Most support needs identified by nurses were similar. CONCLUSION A heterogeneous group of nurses demonstrates overall similar support needs in providing palliative care for persons with dementia and their families in the hospital setting. CLINICAL RELEVANCE Nursing practices should implement dementia-friendly interventions to improve the quality of dementia care in the hospital.
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Affiliation(s)
| | - Sascha R Bolt
- Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | | | - Judith M M Meijers
- Zuyderland, Zuyderland Medical Center, Sittard-Geleen, the Netherlands.,Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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8
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Fischer J, Roßmeier C, Hartmann J, Tensil M, Jox RJ, Diehl-Schmid J, Riedl L. Inappropriate Involvement? Presenting Empirical Insight into the Preparation Phase of Advance Directives of Persons Living with Dementia Under German Legislation. J Aging Soc Policy 2023:1-16. [PMID: 36814064 DOI: 10.1080/08959420.2023.2182565] [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: 02/24/2023]
Abstract
The scholarly debate on advance directives (ADs) in the context of dementia is mainly built around ethical arguments. Empirical studies that shed light into the realities of ADs of persons living with dementia are few and far between and too little is known about the effect of national AD legislation on such realities. This paper offers insight into the preparation phase of ADs according to German legislation in the context of dementia. It presents results from a document analysis of 100 ADs and from 25 episodic interviews with family members. Findings show that drafting an AD involves family members and different professionals in addition to the signatory, whose cognitive impairment differed considerably at the time of preparing the AD. The involvement of family members and professionals is at times problematic, which prompts the question of how much and what kind of involvement of others turns an AD of a person living with dementia into an AD about a person living with dementia. The results invite policy makers to critically review legislation on ADs from the perspective of cognitively impaired persons, who might find it difficult to protect themselves from inappropriate involvement when completing an AD.
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Affiliation(s)
- Julia Fischer
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Carola Roßmeier
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Julia Hartmann
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Maria Tensil
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Janine Diehl-Schmid
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
| | - Lina Riedl
- School of Medicine, Department of Psychiatry and Psychotherapy, Centre for Cognitive Disorders, Technical University of Munich, Munich, Germany
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9
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Bárrios H, Nunes JP, Teixeira JPA, Rego G. Nursing Home Residents Hospitalization at the End of Life: Experience and Predictors in Portuguese Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:947. [PMID: 36673703 PMCID: PMC9859065 DOI: 10.3390/ijerph20020947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 06/17/2023]
Abstract
(1) Background: Nursing Home (NH) residents are a population with health and social vulnerabilities, for whom emergency department visits or hospitalization near the end of life can be considered a marker of healthcare aggressiveness. With the present study, we intend to identify and characterize acute care transitions in the last year of life in Portuguese NH residents, to characterize care integration between the different care levels, and identify predictors of death at hospital and potentially burdensome transitions; (2) Methods: a retrospective after-death study was performed, covering 18 months prior to the emergence of the COVID-19 pandemic, in a nationwide sample of Portuguese NH with 614 residents; (3) Results: 176 deceased patients were included. More than half of NH residents died at hospital. One-third experienced a potentially burdensome care transition in the last 3 days of life, and 48.3% in the last 90 days. Younger age and higher technical staff support were associated with death at hospital and a higher likelihood of burdensome transitions in the last year of life, and Palliative Care team support with less. Advanced Care planning was almost absent; (4) Conclusions: The studied population was frail and old without advance directives in place, and subject to frequent hospitalization and potentially burdensome transitions near the end of life. Unlike other studies, staff provisioning did not improve the outcomes. The results may be related to a low social and professional awareness of Palliative Care and warrant further study.
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Affiliation(s)
- Helena Bárrios
- Hospital do Mar Cuidados Especializados Lisboa, 2695-458 Bobadela, Portugal
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - José Pedro Nunes
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | | | - Guilhermina Rego
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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10
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Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol. BMC Palliat Care 2022; 21:202. [PMID: 36419147 PMCID: PMC9684772 DOI: 10.1186/s12904-022-01097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia. METHODS/DESIGN This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners. DISCUSSION This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.
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11
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Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia. Nurs Clin North Am 2022; 57:259-271. [DOI: 10.1016/j.cnur.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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12
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Palan Lopez R, Hendricksen M, McCarthy EP, Mazor KM, Roach A, Hendrix Rogers A, Epps F, Johnson KS, Akunor H, Mitchell SL. Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study. JAMA Intern Med 2022; 182:313-323. [PMID: 35072703 PMCID: PMC8787681 DOI: 10.1001/jamainternmed.2021.7921] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood. OBJECTIVE To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains. MAIN OUTCOMES AND MEASURES Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values. RESULTS Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits. CONCLUSIONS AND RELEVANCE This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.
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Affiliation(s)
- Ruth Palan Lopez
- Massachusetts General Hospital Institute of Health Professions, School of Nursing, Boston
| | - Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Ashley Roach
- Oregon Health & Science University, School of Nursing, Portland
| | | | - Fayron Epps
- Emory Center for Health in Aging, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.,Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
| | - Harriet Akunor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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13
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Harrad-Hyde F, Armstrong N, Williams C. Using advance and emergency care plans during transfer decisions: A grounded theory interview study with care home staff. Palliat Med 2022; 36:200-207. [PMID: 34866482 PMCID: PMC8796154 DOI: 10.1177/02692163211059343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advance care planning has been identified as one of few modifiable factors that could reduce hospital transfers from care homes. Several types of documents may be used by patients and clinicians to record these plans. However, little is known about how plans are perceived and used by care home staff at the time of deterioration. AIM To describe care home staff experiences and perceptions of using written plans during in-the-moment decision-making about potential resident hospital transfers. DESIGN Qualitative semi-structured interviews analysed using the Straussian approach to grounded theory. SETTING/PARTICIPANTS Thirty staff across six care homes (with and without nursing) in the East and West Midlands of England. RESULTS Staff preferred (in principle) to keep deteriorating residents in the care home but feared that doing so could lead to negative repercussions for them as individuals, especially when there was perceived discordance with family carers' wishes. They felt that clinicians should be responsible for these plans but were happy to take a supporting role. At the time of deterioration, written plans legitimised the decision to care for the resident within the home; however, staff were wary of interpreting broad statements and wanted plans to be detailed, specific, unambiguous, technically 'correct', understood by families and regularly updated. CONCLUSIONS Written plans provide reassurance for care home staff, reducing concerns about personal and professional risk. However, care home staff have limited discretion to interpret plans and transfers may occur if plans are not specific enough for care home staff to use confidently.
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Affiliation(s)
- Fawn Harrad-Hyde
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chris Williams
- Department of Health Sciences, University of Leicester, Leicester, UK
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14
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Abstract
BACKGROUND Dementia is a life-limiting condition that affects 50 million people globally. Existing definitions of end of life do not account for the uncertain trajectory of dementia. People living with dementia may live in the advanced stage for several years, or even die before they reach the advanced stage of dementia. AIM To identify how end of life in people with dementia is measured and conceptualised, and to identify the factors that contribute towards identifying end of life in people with dementia. DESIGN Systematic review and narrative synthesis. DATA SOURCES Electronic databases MEDLINE, EMBASE, PsychInfo and CINAHL, were searched in April 2020. Eligible studies included adults with any dementia diagnosis, family carers and healthcare professionals caring for people with dementia and a definition for end of life in dementia. RESULTS Thirty-three studies met the inclusion criteria. Various cut-off scores from validated tools, estimated prognoses and descriptive definitions were used to define end of life. Most studies used single measure tools which focused on cognition or function. There was no pattern across care settings in how end of life was defined. Healthcare professionals and family carers had difficulty recognising when people with dementia were approaching the end of life. CONCLUSION End-of-life care and research that focuses only on cognitive and functional decline may fail to recognise the complexities and unmet needs relevant to dementia and end of life. Research and clinical practice should adopt a needs-based approach for people with dementia and not define end of life by stage of disease.
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Affiliation(s)
- Bria Browne
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, London, UK
- National Ageing Research Institute, Parkville, Victoria, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, North Middlesex University Hospital, London, UK
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
- Marie Curie Palliative Care Research Department, University College London, London, UK
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15
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Williamson LE, Evans CJ, Cripps RL, Leniz J, Yorganci E, Sleeman KE. Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review. J Am Med Dir Assoc 2021; 22:2046-2055.e35. [PMID: 34273269 DOI: 10.1016/j.jamda.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life. DESIGN Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271). SETTING AND PARTICIPANTS Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life. MEASUREMENTS The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources. RESULTS After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance. CONCLUSIONS AND IMPLICATIONS The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
| | - Rachel L Cripps
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Javiera Leniz
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Emel Yorganci
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
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16
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Hanna N, Quach B, Scott M, Qureshi D, Tanuseputro P, Webber C. Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping Review. J Pain Symptom Manage 2021; 61:1261-1277.e10. [PMID: 33096215 DOI: 10.1016/j.jpainsymman.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Care transitions at the end of life are associated with reduced quality of life and negative health outcomes, yet up to half of patients in developed countries experience a transition within the last month of life. A variety of these transitions have been described as "burdensome" in the literature; however, there is currently no consensus on the definition of a burdensome transition. OBJECTIVES The purpose of this review was to identify current definitions of "burdensome transitions" and develop a framework for classifying transitions as "burdensome" at the end of life. METHODS A search was conducted in databases including Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, CINAHL, and PsychINFO for articles published in English between January 1, 2000 and September 28, 2019. RESULTS A total of 37 articles met inclusion criteria for this scoping review. Definitions of burdensome transitions were characterized by the following features: transition setting trajectory, number of transitions, temporal relationship to end of life, or quality of transitions. CONCLUSION Definitions of burdensome transitions varied based on time before death, setting of cohorts, and study population. These definitions can be helpful in identifying and subsequently preventing unnecessary transitions at the end of life.
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Affiliation(s)
- Nardin Hanna
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Bradley Quach
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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17
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Keijzer-van Laarhoven AJ, Touwen DP, Tilburgs B, van Tilborg-den Boeft M, Pees C, Achterberg WP, van der Steen JT. Which moral barriers and facilitators do physicians encounter in advance care planning conversations about the end of life of persons with dementia? A meta-review of systematic reviews and primary studies. BMJ Open 2020; 10:e038528. [PMID: 33184079 PMCID: PMC7662455 DOI: 10.1136/bmjopen-2020-038528] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE AND OBJECTIVE Conducting advance care planning (ACP) conversations with people with dementia and their relatives contributes to providing care according to their preferences. In this review, we identify moral considerations which may hinder or facilitate physicians in conducting ACP in dementia. DESIGN For this meta-review of systematic reviews and primary studies, we searched the PubMed, Web of Science and PsycINFO databases between 2005 and 30 August 2019. We included empirical studies concerning physicians' moral barriers and facilitators of conversations about end-of-life preferences in dementia care. The protocol was registered at Prospero (CRD42019123308). SETTING AND PARTICIPANTS Physicians and nurse practitioners providing medical care to people with dementia in long-term and primary care settings. We also include observations from patients or family caregivers witnessing physicians' moral considerations. MAIN OUTCOMES Physicians' moral considerations involving ethical dilemmas for ACP. We define moral considerations as the weighing by the professional caregiver of values and norms aimed at providing good care that promotes the fundamental interests of the people involved and which possibly ensues dilemmas. RESULTS Of 1347 studies, we assessed 22 systematic reviews and 51 primary studies as full texts. We included 11 systematic reviews and 13 primary studies. Themes included: (1) beneficence and non-maleficence; (2) respecting dignity; (3) responsibility and ownership; (4) relationship and (5) courage. Moral dilemmas related to the physician as a professional and as a person. For most themes, there were considerations that either facilitated or hindered ACP, depending on physician's interpretation or the context. CONCLUSIONS Physicians feel a responsibility to provide high-quality end-of-life care to patients with dementia. However, the moral dilemmas this may involve, can lead to avoidant behaviour concerning ACP. If these dilemmas are not recognised, discussed and taken into account, implementation of ACP as a process between physicians, persons with dementia and their family caregivers may fail.
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Affiliation(s)
- Angela Jjm Keijzer-van Laarhoven
- Department of Expertise and Treatment, Argos Zorggroep, Schiedam, The Netherlands
- Department of Medical Ethics and Health Law (E&R), Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Expertise and Treatment, Laurens, Rotterdam, The Netherlands
| | - Dorothea P Touwen
- Department of Medical Ethics and Health Law (E&R), Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Bram Tilburgs
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Madelon van Tilborg-den Boeft
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Quin, Amsterdam, The Netherlands
| | - Claudia Pees
- Walaeus Library, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Leiden, The Netherlands
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18
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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19
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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20
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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21
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Rainsford S, Johnston N, Liu WM, Glasgow N, Forbat L. Palliative care Needs Rounds in rural residential aged care: A mixed-methods study exploring experiences and perceptions of staff and general practitioners. PROGRESS IN PALLIATIVE CARE 2019. [DOI: 10.1080/09699260.2019.1698177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Suzanne Rainsford
- Medical School, Australian National University, Canberra, Australia
- Calvary Health Care Bruce – Clare Holland House, Canberra, Australia
| | - Nikki Johnston
- Calvary Health Care Bruce – Clare Holland House, Canberra, Australia
| | - Wai-Man Liu
- Research School of Finance, Actuarial Studies and Statistics, College of Business and Economics, Australian National University, Canberra, Australia
| | - Nicholas Glasgow
- Medical School, Australian National University, Canberra, Australia
- Calvary Health Care Bruce – Clare Holland House, Canberra, Australia
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
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22
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Austin AM, Carmichael DQ, Bynum JPW, Skinner JS. Measuring racial segregation in health system networks using the dissimilarity index. Soc Sci Med 2019; 240:112570. [PMID: 31585377 PMCID: PMC6810808 DOI: 10.1016/j.socscimed.2019.112570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/12/2019] [Accepted: 09/24/2019] [Indexed: 11/28/2022]
Abstract
Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon.
| | - Donald Q Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor MI, USA; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor MI, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Dartmouth College, Hanover, NH, USA; Department of Economics, Dartmouth College, Hanover NH, USA
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23
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Unroe KT, O'Kelly Phillips E, Effler S, Ersek MT, Hickman SE. Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project. J Pain Symptom Manage 2019; 58:559-566. [PMID: 31233842 DOI: 10.1016/j.jpainsymman.2019.06.012] [Citation(s) in RCA: 5] [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: 05/02/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur. OBJECTIVES Describe nursing facility residents with comfort measures and their hospital transfers. METHODS Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods. RESULTS Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care. CONCLUSION Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA.
| | | | | | - Mary T Ersek
- Department of Veterans Affairs, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Susan E Hickman
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University School of Nursing, Indianapolis, Indiana, USA
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Progress in advance care planning among nursing home residents dying with advanced dementia-Does it make any difference in end-of-life care? Arch Gerontol Geriatr 2019; 86:103955. [PMID: 31561064 DOI: 10.1016/j.archger.2019.103955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increased awareness of the clinical course of nursing home residents with advanced dementia and advance care planning (ACP) has become the cornerstone of good palliative care. OBJECTIVE The aim of our study is to describe changes in ACP in the form of physician treatment orders (PTOs), symptom prevalence and possible burdensome interventions among nursing home (NH) residents who died between 2004-2009 and 2010-2013 METHODS: Retrospective study RESULTS: The number of PTOs regarding forgoing antibiotics or parenteral antibiotics, forgoing artificial nutrition or hydration or forgoing hospitalisation doubled between 2004-2009 and 2010-2013 (38.1% vs. 64.9%, p < 0.001; 40.0% vs. 81.7%, p < 0.001; 28.1% vs. 69.5%, p < 0.001, respectively). PTOs were also done significantly earlier in 2010-2013 than in 2004-2009. The prevalence of distressing symptoms and possible burdensome interventions remained unchanged, although the prevalence of consistency with the PTOs was high. CONCLUSION Despite the increased number of PTOs, this had little effect on symptom prevalence and possible burdensome interventions experienced by NH residents in the last days of life.
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Leniz J, Higginson IJ, Stewart R, Sleeman KE. Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study. Age Ageing 2019; 48:672-679. [PMID: 31135024 DOI: 10.1093/ageing/afz052] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/20/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable. OBJECTIVE to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia. DESIGN retrospective cohort study. SETTING electronic records from a mental health provider in London, linked to national mortality and hospital data. SUBJECTS people with dementia who died in 2007-2016. METHODS end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression. RESULTS of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001). CONCLUSIONS in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.
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Affiliation(s)
- Javiera Leniz
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
| | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience; South London and Maudsley NHS Foundation Trust, Biomedical Research Centre, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
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Pecanac KE, Wyman M, Kind AJH, Voils CI. Treatment decision making involving patients with dementia in acute care: A scoping review. PATIENT EDUCATION AND COUNSELING 2018; 101:1884-1891. [PMID: 29980337 PMCID: PMC6179913 DOI: 10.1016/j.pec.2018.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/06/2018] [Accepted: 06/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To summarize the evidence regarding the factors and processes of treatment decision making involving a person with dementia (PWD) in the acute care setting. METHODS We conducted a scoping review, searching 4 databases (PubMed, CINAHL, Web of Science, & PsychINfo) for articles that contained primary data from a quantitative or qualitative study involving treatment decision making in the acute care setting for PWD and were published in English. We categorized the factors and processes of decision making identified in each article using inductive content analysis. We also consulted with healthcare practitioners to receive stakeholder input on our findings. RESULTS Our search initially revealed 12,478 articles, of which 28 were included in the review. We identified 5 categories of factors that influence the decision-making process: knowing the patient, culture and systems, role clarity, appropriateness of palliative care in dementia, and caregiver need for support. CONCLUSION Our findings highlight the complexities of the decision-making process and the importance of attending to the needs of the caregiver, healthcare practitioners, and the patient. PRACTICE IMPLICATIONS It is important to address beliefs of involving palliative care for a PWD and the role of each healthcare discipline.
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Affiliation(s)
| | - Mary Wyman
- William S. Middleton Memorial Veterans Hospital, Madison, USA; Department of Psychiatry, University of Wisconsin, School of Medicine and Public Health, Madison, USA.
| | - Amy J H Kind
- William S. Middleton Memorial Veterans Hospital, Madison, USA; Department of Medicine, University of Wisconsin, School of Medicine & Public Health, Madison, USA.
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, USA; Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, USA.
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Toles M, Song MK, Lin FC, Hanson LC. Perceptions of Family Decision-makers of Nursing Home Residents With Advanced Dementia Regarding the Quality of Communication Around End-of-Life Care. J Am Med Dir Assoc 2018; 19:879-883. [PMID: 30032997 DOI: 10.1016/j.jamda.2018.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/18/2018] [Accepted: 05/20/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES (1) Compare family decision-makers' perceptions of quality of communication with nursing home (NH) staff (nurses and social workers) and clinicians (physicians and other advanced practitioners) for persons with advanced dementia; (2) determine the extent to which characteristics of NH residents and family decision-makers are associated with those perceptions. DESIGN Secondary analysis of baseline data from a cluster randomized trial of the Goals of Care intervention. SETTING Twenty-two NHs in North Carolina. PARTICIPANTS Family decision-makers of NH residents with advanced dementia (n = 302). MEASUREMENTS During the baseline interviews, family decision-makers rated the quality of general communication and communication specific to end-of-life care using the Quality of Communication Questionnaire (QoC). QoC item scores ranged from 0 to 10, with higher scores indicating better quality of communication. Linear models were used to compare QoC by NH provider type, and to test for associations of QoC with resident and family characteristics. RESULTS Family decision-makers rated the QoC with NH staff higher than NH clinicians, including average overall QoC scores (5.5 [1.7] vs 3.7 [3.0], P < .001), general communication subscale scores (8.4 [1.7] vs 5.6 [4.3], P < .001), and end-of-life communication subscale scores (3.0 [2.3] vs 2.0 [2.5], P < .001). Low scores reflected failure to communicate about many aspects of care, particularly end-of-life care. QoC scores were higher with later-stage dementia, but were not associated with the age, gender, race, relationship to the resident, or educational attainment of family decision-makers. CONCLUSION Although family decision-makers for persons with advanced dementia rated quality communication with NH staff higher than that with clinicians, they reported poor quality end-of-life communication for both staff and clinicians. Clinicians simply did not perform many communication behaviors that contribute to high-quality end-of-life communication. These omissions suggest opportunities to clarify and improve interdisciplinary roles in end-of-life communication for residents with advanced dementia.
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Affiliation(s)
- Mark Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Mi-Kyung Song
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Feng-Chang Lin
- Gillings School of Global Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura C Hanson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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