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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 2024:2692163241269671. [PMID: 39177080 DOI: 10.1177/02692163241269671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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Chen BA, Lai FC, Tsao LI, Chien HH, Chen CF, Jeng C. Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study. J Adv Nurs 2021; 77:2728-2738. [PMID: 33624335 DOI: 10.1111/jan.14802] [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: 09/02/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Abstract
AIMS To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors. DESIGN A cross-sectional nationwide study. METHODS The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods. RESULTS In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001). CONCLUSIONS Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment. IMPACT What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.
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Affiliation(s)
- Bor-An Chen
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan.,Department of Nursing, Ching Kuo Institute of Management and Health, Keelung, Taiwan
| | - Fu-Chih Lai
- Post-Baccalaureate Nursing Program in Nursing and College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Lee-Ing Tsao
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Hui-Hui Chien
- Nursing Department, Yuanshan Branch, Taipei Veterans General Hospital, Ilan, Taiwan
| | - Chun-Fu Chen
- Taipei Medical University-Shuang HO Hospital, Ministry of Health and Welfare
| | - Chii Jeng
- School of Nursing, Taipei Medical University, Taipei, Taiwan
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Ten Koppel M, Pasman HRW, van der Steen JT, van Hout HPJ, Kylänen M, Van den Block L, Smets T, Deliens L, Gambassi G, Froggatt K, Szczerbińska K, Onwuteaka-Philipsen BD. Consensus on treatment for residents in long-term care facilities: perspectives from relatives and care staff in the PACE cross-sectional study in 6 European countries. BMC Palliat Care 2019; 18:73. [PMID: 31464624 PMCID: PMC6714096 DOI: 10.1186/s12904-019-0459-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 08/15/2019] [Indexed: 01/23/2023] Open
Abstract
Background In long-term care facilities often many care providers are involved, which could make it difficult to reach consensus in care. This may harm the relation between care providers and can complicate care. This study aimed to describe and compare in six European countries the degree of consensus among everyone involved in care decisions, from the perspective of relatives and care staff. Another aim was to assess which factors are associated with reporting that full consensus was reached, from the perspective of care staff and relatives. Methods In Belgium, England, Finland, Italy, the Netherlands and Poland a random sample of representative long-term care facilities reported all deaths of residents in the previous three months (n = 1707). This study included residents about whom care staff (n = 1284) and relatives (n = 790) indicated in questionnaires the degree of consensus among all involved in the decision or care process. To account for clustering on facility level, Generalized Estimating Equations were conducted to analyse the degree of consensus across countries and factors associated with full consensus. Results Relatives indicated full consensus in more than half of the residents in all countries (NL 57.9% - EN 68%), except in Finland (40.7%). Care staff reported full consensus in 59.5% of residents in Finland to 86.1% of residents in England. Relatives more likely reported full consensus when: the resident was more comfortable or talked about treatment preferences, a care provider explained what palliative care is, family-physician communication was well perceived, their relation to the resident was other than child (compared to spouse/partner) or if they lived in Poland or Belgium (compared to Finland). Care staff more often indicated full consensus when they rated a higher comfort level of the resident, or if they lived in Italy, the Netherland, Poland or England (compared to Finland). Conclusions In most countries the frequency of full consensus among all involved in care decisions was relatively high. Across countries care staff indicated full consensus more often and no consensus less often than relatives. Advance care planning, comfort and good communication between relatives and care professionals could play a role in achieving full consensus. Electronic supplementary material The online version of this article (10.1186/s12904-019-0459-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Ten Koppel
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands.
| | - H R W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
| | - J T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - H P J van Hout
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, The Netherlands
| | - M Kylänen
- National Institute for Health and Welfare, Mannerheimintie, 166, Helsinki, Finland
| | - L Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - T Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - L Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan, 103, Brussels, Belgium
| | - G Gambassi
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | - K Froggatt
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, LA1 4YG, UK
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, ul. Kopernika 7a, Krakow, Poland
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
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Rababa M. Association of Comorbid Burden and Patient Outcomes of Residents With Dementia in Jordanian Nursing Homes. J Gerontol Nurs 2018; 44:50-58. [PMID: 29969140 DOI: 10.3928/00989134-20180614-08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 04/02/2018] [Indexed: 12/20/2022]
Abstract
Medical and psychiatric comorbidity in individuals with dementia is often associated with serious adverse health outcomes. Using a convenience sample of 76 residents with dementia in Jordanian nursing homes, the current study aimed to examine the relationship among comorbid burden, ability to verbally self-report symptoms, severity of dementia, and patient outcomes of pain and agitation. Comorbid burden and ability to verbally self-report symptoms were found to be significant predictors of patient outcomes of pain and agitation. However, the ability to verbally self-report symptoms did not explain the relationship between comorbid burden and patient outcomes. Nurses must understand the impact of comorbid burden and the ability to verbally self-report symptoms regarding pain and agitation in individuals with dementia. [Journal of Gerontological Nursing, 44(7), 50-58.].
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Cohen-Mansfield J, Lipson S. Medical Decision-Making around the Time of Death of Cognitively Impaired Nursing Home Residents: A Pilot Study. OMEGA-JOURNAL OF DEATH AND DYING 2016; 48:103-14. [PMID: 15688544 DOI: 10.2190/4j17-px0v-wq03-cgda] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The purpose of this article is to describe the end-of-life process in the nursing home for three groups of cognitively–impaired nursing home residents: those who died with a medical decision-making process prior to death; those who died without such a decision-making process; and those who had a status–change event and a medical decision-making process, and did not die prior to data collection. Residents had experienced a medical status–change event within the 24 hours prior to data collection, and were unable to make their own decisions due to cognitive impairment. Data on the decision-making process during the event, including the type of event, the considerations used in making the decisions, and who was involved in making these decisions were collected from the residents' charts and through interviews with their physicians or nurse practitioners. When there was no decision-making process immediately prior to death, a decision-making process was usually reported to have occurred previously, with most decisions calling either for comfort care or limitation of care. When comparing those events leading to death with other status–change events, those who died were more likely to have suffered from troubled breathing than those who remained alive. Hospitalization was used only among those who survived, whereas diagnostic tests and comfort care were used more often with those who died. Those who died had more treatments considered and chosen than did those who remained alive. For half of those who died, physicians felt that they would have preferred less treatment for themselves if they were in the place of the decedents. The results represent preliminary data concerning decision-making processes surrounding death of the cognitively–impaired in the nursing home. Additional research is needed to elucidate the trends uncovered in this study.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Research Institute on Aging, Hebrew Home of Greater Washington, 6121 Montrose Road, Rockville, MD 20852, USA.
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Marcantonio ER, O'Malley AJ, Murkofsky RL, Caudry DJ, Buchanan JL. Derivation and Confirmation of Scales Measuring Medical Directors’ Attitudes About the Hospitalization of Nursing Home Residents. J Aging Health 2016; 18:869-84. [PMID: 17099138 DOI: 10.1177/0898264306293617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To derive and confirm scales measuring medical director’s attitudes about hospitalization of nursing home residents. Method: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales. Results: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations. Discussion: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.
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Uematsu H, Kunisawa S, Yamashita K, Imanaka Y. The Impact of Patient Profiles and Procedures on Hospitalization Costs through Length of Stay in Community-Acquired Pneumonia Patients Based on a Japanese Administrative Database. PLoS One 2015; 10:e0125284. [PMID: 25923785 PMCID: PMC4414582 DOI: 10.1371/journal.pone.0125284] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/22/2015] [Indexed: 11/25/2022] Open
Abstract
Background Community-acquired pneumonia is a common cause of patient hospitalization, and its burden on health care systems is increasing in aging societies. In this study, we aimed to investigate the factors that affect hospitalization costs in community-acquired pneumonia patients while considering the intermediate influence of patient length of stay. Methods Using a multi-institutional administrative claims database, we analyzed 30,041 patients hospitalized for community-acquired pneumonia who had been discharged between April 1, 2012 and September 30, 2013 from 289 acute care hospitals in Japan. Possible factors associated with hospitalization costs were investigated using structural equation modeling with length of stay as an intermediate variable. We calculated the direct, indirect (through length of stay), and total effects of the candidate factors on hospitalization costs in the model. Lastly, we calculated the ratio of indirect effects to direct effects for each factor. Results The structural equation model showed that higher disease severities (using A-DROP, Barthel Index, and Charlson Comorbidity Index scores), use of mechanical ventilation, and tube feeding were associated with higher hospitalization costs, regardless of the intermediate influence of length of stay. The severity factors were also associated with longer length of stay durations. The ratio of indirect effects to direct effects on total hospitalization costs showed that the former was greater than the latter in the factors, except in the use of mechanical ventilation. Conclusions Our structural equation modeling analysis indicated that patient profiles and procedures impacted on hospitalization costs both directly and indirectly. Furthermore, the profiles were generally shown to have greater indirect effects (through length of stay) on hospitalization costs than direct effects. These findings may be useful in supporting the more appropriate distribution of health care resources.
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Affiliation(s)
- Hironori Uematsu
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
- Department of Biomedical Sciences, Ritsumeikan University, Kyoto City, Kyoto, Japan
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto City, Kyoto, Japan
- * E-mail:
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The frequency of and reasons for acute hospital transfers of older nursing home residents. Arch Gerontol Geriatr 2014; 58:115-20. [DOI: 10.1016/j.archger.2013.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 08/03/2013] [Accepted: 08/07/2013] [Indexed: 11/19/2022]
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Arendts G, Quine S, Howard K. Decision to transfer to an emergency department from residential aged care: A systematic review of qualitative research. Geriatr Gerontol Int 2013; 13:825-33. [DOI: 10.1111/ggi.12053] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Susan Quine
- School of Public Health; University of Sydney; Sydney; New South Wales; Australia
| | - Kirsten Howard
- School of Public Health; University of Sydney; Sydney; New South Wales; Australia
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van de Bovenkamp HM, Trappenburg MJ. Comparative review of family-professional communication: what mental health care can learn from oncology and nursing home care. Int J Ment Health Nurs 2012; 21:366-85. [PMID: 22510087 DOI: 10.1111/j.1447-0349.2011.00798.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Because family members take on caring tasks and also suffer as a consequence of the illness of the patient, communication between health-care professionals and family members of the patient is important. This review compares communication practices between these two parties in three different parts of health care: oncology, nursing home care, and mental health care. It shows that there are important differences between sectors. Mental health stands out because contacts between family members and professionals are considered problematic due to the autonomy and confidentiality of the patient. The article explores several explanations for this, and, by comparing the three health sectors, distils lessons to improve the relationship between family members and health-care professionals.
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Palan Lopez R. Doing what's best: decisions by families of acutely Ill nursing home residents. West J Nurs Res 2009; 31:613-26. [PMID: 19321882 DOI: 10.1177/0193945909332911] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When nursing home residents experience acute illness, the preference of family members is a major consideration in the choice between aggressive treatment and palliative care. Grounded theory method was used to explore decision making by family members of acutely ill nursing home residents. Analysis of 12 in-depth interviews with family members resulted in a theory, "doing what's best," that describes the basic psychosocial problem and response of family members. The problem was to make treatment decisions in the face of uncertain circumstances, and the response consisted of five subprocesses: protecting life, creating comfort, relying on religion, honoring wishes, and seeking guidance. Application of this theory to nursing practice can help nurses identify sources of uncertainty and support family members to clarify priorities for life prolongation or comfort, rely on religious or spiritual solace, translate resident wishes into individualized care plans, and provide knowledgeable guidance and support throughout the decision-making process.
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Affiliation(s)
- Ruth Palan Lopez
- MGH Institute of Health Professions, Boston, University of Pennsylvania, Philadelphia, USA
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Cohen-Mansfield J, Lipson S. Which Advance Directive Matters? An Analysis of End-of-Life Decisions Made in Nursing Homes. Res Aging 2008. [DOI: 10.1177/0164027507307925] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study clarifies the role of advance directives in the process of decision making in nursing homes. Physicians reported on the actual use of advance directives in a medical decision-making process related to status changes in 70 nursing home residents (mean age = 89 years). Charts were also reviewed to assess the specifics of the advance directives. Despite a high prevalence of advance directives, the directives themselves had a very limited role in affecting treatments. The physicians surveyed viewed directives related to hospitalization as the most useful, though these were not the most available directives. The attention and format given to advance directives in the nursing home may need to be reevaluated.
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Affiliation(s)
| | - Steven Lipson
- Research Institute on Aging of the Hebrew Home of Greater
Washington
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Abstract
Nursing home-associated pneumonia (NHAP) is associated with considerable morbidity and mortality. The etiology of NHAP continues to be debated and has influenced treatment guideline recommendations. Diagnosis may not be straightforward but at least one respiratory symptom usually is present and the presence of hypoxemia is a key finding. Treatment recommendations vary depending on the organisms believed the predominant cause of NHAP. Pneumococcal and influenza vaccination remain the most important methods for prevention of NHAP at present.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY 14215, USA.
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Cohen-Mansfield J, Lipson S. To hospitalize or not to hospitalize? That is the question: an analysis of decision making in the nursing home. Behav Med 2007; 32:64-70. [PMID: 16903616 DOI: 10.3200/bmed.32.2.64-70] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The authors examined the processes and factors that influence physicians' decision-making processes as regarding hospitalization of nursing home residents. In a large nonprofit nursing home, 6 full-time male physicians and 1 female nurse practitioner completed questionnaires that described the medical decision-making process for 52 nursing home residents for whom hospitalization was considered. The questionnaire covered the following topics: medical event description, the decision-making process, considerations in making treatment decisions, and the role of advance directives. Hospitalized residents had fewer treatments considered and fewer treatments chosen than those who were not hospitalized. Residents with fractures were the most commonly hospitalized residents, whereas residents in frailer conditions, with breathing problems, and for whom the physician considered quality of life to be most important were less likely to be hospitalized. The results of this study clarify the complexity of factors affecting the decision-making process and suggest a methodology that may assist in discerning those factors in the future.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Research Institute on Aging of the Hebrew Home of Greater Washington, Rockville, MD 20852, USA.
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Cohen-Mansfield J, Lipson S, Horton D. Medical Decision-Making in the Nursing Home: A Comparison of Physician and Nurse Perspectives. J Gerontol Nurs 2006; 32:14-21. [PMID: 17190402 DOI: 10.3928/00989134-20061201-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family's and resident's wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians' reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.
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Buchanan JL, Murkofsky RL, O'Malley AJ, Karon SL, Zimmerman D, Caudry DJ, Marcantonio ER. Nursing Home Capabilities and Decisions to Hospitalize: A Survey of Medical Directors and Directors of Nursing. J Am Geriatr Soc 2006; 54:458-65. [PMID: 16551313 DOI: 10.1111/j.1532-5415.2005.00620.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents. DESIGN Cross-sectional survey. SETTING Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states. PARTICIPANTS Medical directors and directors of nursing (DONs). MEASUREMENTS Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice. RESULTS The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive. CONCLUSION Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.
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Affiliation(s)
- Joan L Buchanan
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Bercovitz A, Gruber-Baldini AL, Burton LC, Hebel JR. Healthcare utilization of nursing home residents: comparison between decedents and survivors. J Am Geriatr Soc 2006; 53:2069-75. [PMID: 16398889 DOI: 10.1111/j.1532-5415.2005.00489.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether residents who die while in the nursing home have higher healthcare utilization than survivors and whether the utilization in the periods before death varies with length of stay in the nursing home. DESIGN Descriptive, longitudinal study comparing medical service use of residents who died during the study period with that of residents who remained alive in the facility. SETTING Fifty-nine nursing homes in Maryland. Data were collected between 1992 and 1995. PARTICIPANTS A random sample of 1,195 residents. MEASUREMENTS Rates of hospitalization, emergency department visits, and medical visits in aggregate and in an initial 30-day and subsequent 90-day intervals after admission to the nursing home. RESULTS Residents who died during the 2-year study period had significantly greater mean rates of utilization of all types of health care than residents who were not discharged from the nursing home, even when controlling for dementia diagnosis, age, functional status, and number of comorbid conditions. Those who died within a month of admission had significantly more emergency department and medical visits than those who died after a longer stay. CONCLUSION The pattern of high healthcare utilization before death is consistent with studies of the overall Medicare population that show an increase in Medicare expenditures in the period before death.
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Affiliation(s)
- Anita Bercovitz
- Division of Gerontology, School of Medicine, University of Maryland, Baltimore, Maryland 21201, USA.
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Abstract
The management of nursing home-acquired pneumonia (NHAP) continues to be debatable because of the lack of clinical trials and controversy regarding its aetiology. The controversy regarding aetiology stems, in part, from studies that utilised sputum cultures for the diagnosis of NHAP without assessing the quality of the samples. These studies found a high proportion of Gram-negative aerobic bacilli in cultures as well as Staphylococcus aureus. However, in studies that have assessed the reliability of sputum samples, Gram-negative bacilli and S. aureus were isolated infrequently and Streptococcus pneumoniae and Haemophilus influenzae isolated most commonly. Since Gram-negative aerobic bacilli and S. aureus frequently cause hospital-acquired pneumonia, some authors have considered NHAP to be a variant of this group. Many other studies, however, have considered NHAP as part of the community-acquired pneumonia category. Depending on which categorisation is used for NHAP, the treatment recommendations have varied. There are several factors to consider in the management of NHAP in addition to choice of antibacterial: hospitalisation decision, initial route of administration of antibacterials for treatment in the nursing home, timing of switch from a parenteral to an oral agent and the duration of therapy. These factors, which have not been addressed in published guidelines, are discussed in this review. Recent guidelines recommend a fluoroquinolone (gatifloxacin, levofloxacin or moxifloxacin) or amoxicillin/clavulanic acid plus a macrolide for initial treatment of NHAP in the nursing home. For treatment in the hospital, a parenteral fluoroquinolone (as listed above) or a second- or third-generation cephalosporin plus a macrolide is recommended. A recent guideline for the treatment of healthcare-associated pneumonia (that includes NHAP) recommended an antipseudomonal cephalosporin or a carbapenem or an antipseudomonal penicillin/beta-lactamase inhibitor plus ciprofloxacin plus vancomycin or linezolid for treatment of NHAP based on findings in residents with severe pneumonia who required mechanical ventilation. However, this recommendation does not apply to the majority of residents who are hospitalised with pneumonia and not intubated. Other factors to consider when choosing an empiric regimen include recent antibacterial therapy and prior colonisation with a resistant organism, e.g. methicillin-resistant S. aureus. Recently, a group of studies by investigators in The Netherlands have focused on the concept of withholding antibacterial therapy in nursing home residents with pneumonia who have advanced dementia. These studies are reviewed in some detail because this is an approach to the management of NHAP that is uncommon but deserves more consideration given the terminal status of these people. Future studies of NHAP should focus on development of rapid (molecular) methods to identify aetiological agents, determination of the optimum antimicrobial regimen and duration of therapy, and identification of criteria that can assist physicians and families in making the decision to withhold antimicrobial therapy in residents with advanced dementia and pneumonia.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA.
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Allen RS, Burgio LD, Fisher SE, Michael Hardin J, Shuster JL. Behavioral characteristics of agitated nursing home residents with dementia at the end of life. THE GERONTOLOGIST 2005; 45:661-6. [PMID: 16199401 PMCID: PMC2710512 DOI: 10.1093/geront/45.5.661] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive status who did not die during the trial. DESIGN AND METHODS We conducted a two-group secondary data analysis of prospective observational data from 10 nursing homes in Birmingham, Alabama. By means of chart review, resident assessments, surveys of certified nursing assistants, and direct observation of residents' daily behaviors and environment, 32 residents (87.34 +/- 7.29 years) with a Mini-Mental State Examination (MMSE) score = 4.31 (+/-5.54) who died were compared with 32 residents (84 +/- 6.96 years) with a mean MMSE score = 4.28 (+/-5.49) who did not die during the clinical trial. RESULTS Residents who died displayed more verbal agitation, less time in verbal interaction with staff, and almost twice as much time restrained in bed during observation time in comparison with residents who did not die during the clinical trial. However, groups did not differ significantly in severity of comorbid illness, functional status, number of painful diagnoses, certified nursing assistants' reports of residents' pain, or opioid or nonopioid analgesic prescription or dosage. Surviving residents were more likely to receive neuroleptic medication than residents who died. IMPLICATIONS Results suggest that agitated nursing home residents may exhibit a heightened level of verbal agitation, decreased verbal interaction with staff, and increased bed restraint up to 3 months prior to death. Prospective observational studies are needed to identify markers for imminent mortality among nursing home residents.
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Affiliation(s)
- Rebecca S Allen
- Department of Psychology, The University of Alabama, Tuscaloosa, 35487-0315, USA.
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Konetzka RT, Spector W, Shaffer T. Effects of nursing home ownership type and resident payer source on hospitalization for suspected pneumonia. Med Care 2004; 42:1001-8. [PMID: 15377933 DOI: 10.1097/00005650-200410000-00009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether to hospitalize residents with suspected pneumonia is a complex decision determined both by clinical and financial considerations. The decision to hospitalize may be different in for-profit and not-for-profit facilities and for different payment sources. OBJECTIVE The objective of this study was to examine the role of proprietary status in the decision to hospitalize residents with suspected pneumonia, controlling for facility- and resident-level factors. DATA AND METHODS The analysis uses the 1996 Medical Expenditure Panel Survey Nursing Home Component, a nationally representative sample of 5899 nursing home residents in 815 facilities. During the year, 766 elderly residents in the sample were suspected of having pneumonia infections and 224 were hospitalized for them. Logistic regression is used to assess factors affecting the decision to hospitalize among the 766 with pneumonia infections. MAIN OUTCOME MEASURE Hospitalization for suspected pneumonia. RESULTS Residents with suspected pneumonia in not-for-profit facilities are hospitalized at a rate half that of for-profit facilities. The difference is most pronounced for residents who are older and more cognitively impaired and those who are covered by Medicare or private funds. Medicaid residents are most likely overall to be hospitalized, with higher rates in not-for-profit than for-profit facilities. CONCLUSION Risk of hospitalization for suspected pneumonia varies widely by ownership type and resident payer source, with lowest overall risk in not-for-profit facilities. Higher Medicaid hospitalization in not-for-profit facilities is consistent with heterogeneity in the not-for-profit sector, where Medicaid residents are sorted into the lower-quality facilities.
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Affiliation(s)
- R Tamara Konetzka
- Department of Health Studies, The University of Chicago, Chicago, Illinois 60637, USA.
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Cohen-Mansfield J, Lipson S, Horton D. Which signs and symptoms warrant involvement of medical staff? The definition and identification of status-change events in the nursing home. Behav Med 2004; 29:115-20. [PMID: 15206830 DOI: 10.1080/08964280309596064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this article, the authors clarify the concept of status-change events (a significant clinical change that calls for medical follow-up by a physician) by providing preliminary descriptions of these events, and attempting to differentiate them from incidents that did not qualify as status-change events. Participants were residents from a large, nonprofit nursing home. Data were collected about the source of information, the nature of the incident, whether it qualified as a status-change event, and the reason (if any) for disqualification. The most common incidents involved in status-change events were troubled breathing, aspiration, fracture, and hypotension. The most common incidents that did not qualify as status-change events were continuing pneumonia, bruises, lacerations, disorientation, and blood pressure abnormalities. A wide range of physical ailments characterized both status-change events and incidents that did not qualify as status-change events. The main reason an incident did not qualify was because it did not warrant contacting the physician. The nature of the incident is insufficient in itself to determine whether the incident qualifies as a status-change event. The process for identifying and analyzing status-change events in the nursing home requires several steps and much persistence.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Research Institute on Aging, Hebrew Home of Greater Washington, George Washington University Medical Center, Rockville, MD 20852, USA.
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Abstract
OBJECTIVES To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents. DESIGN Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations. SETTING Two hundred fifty-three nursing homes. PARTICIPANTS Eight to 16 randomly selected residents from each facility, totaling 2,080. MEASUREMENTS Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility. RESULTS Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a 10 dollar increase in 1993 Medicaid reimbursement rate above the mean rate of approximately 75 dollars resulted in a 9% reduction in a resident's risk of hospitalization (P<.05). CONCLUSION State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization.
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Affiliation(s)
- Orna Intrator
- Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island 02912, USA.
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