Hospitalization patterns and palliation in the last year of life among residents in long-term care

Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping Review

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.

Integration of Inpatient and Residential Care In-Reach Service Model and Hospital Resource Utilization: A Retrospective Audit

OBJECTIVE

In parts of Australia, Residential In-Reach (RIR) services have been implemented to treat residential aged care (RAC) residents for acute conditions in their place of residence to avoid preventable hospital presentation. Our service was initiated in 2009 and restructured in 2014. We compared acute healthcare resource utilization (RIR activity and emergency hospital presentations) by RAC residents under 2 RIR models of care.

DESIGN

Acute RAC RIR service model of care was changed from existing nurse/emergency physician-led service to nurse/geriatrician-led service and incorporate inpatient liaison nurse consultant into the team.

SETTING

RAC episodes and hospital presentations from a single tertiary referral hospital and its associated RAC RIR service.

METHODS

Retrospective audit comparing RIR activity, hospital presentations, and associated costs from 2 12-month periods, prior to and postimplementation. Data were expressed as a proportion of the total number of RAC beds in the hospital RIR catchment.

RESULTS

After implementation of the new model of care, RIR episodes of care increased from 589 to 985 (15.3 vs 24.7 episodes/100 RAC beds, P < .001). Emergency department (ED) presentations fell from 1616 to 1478 (41.9 vs 37.2 presentations/100 RAC beds, P < .001). There were fewer unplanned ED presentations by RIR patients (2.4% vs 0.8%, = 0.03) and fewer 28-day ED re-presentations (16.8% vs 13.7%, P = .01) under the new model of care. ED cost [$AUD 30,830 vs $28,030/100 RAC beds ($USD 21,344 vs $19,407), P < .001] and inpatient admission costs [$145,607 vs $117,531/100 RAC beds ($USD 100,814 vs $81,380), P < .001] were each lower in the second period.

CONCLUSIONS AND IMPLICATIONS

In the 12 months following implementation of the new model of care, an increase in RIR activity, and a decrease in ED presentations was observed. Further research is necessary to validate these retrospective findings and better evaluate clinical outcomes and consumer satisfaction of the service.

Care home residents who die in hospital: exploring factors, processes and experiences

BACKGROUND

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.

METHODS

This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.

RESULTS

During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.

CONCLUSIONS

Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.

Hospitalizations of nursing home residents at the end of life: A systematic review

BACKGROUND

End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable.

AIM

We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents.

DESIGN

Systematic review (PROSPERO registration number CRD42017072276).

DATA SOURCES

A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions.

RESULTS

A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings.

CONCLUSION

There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.

Care workers' view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study

Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n = 33) and nursing staff (n = 146) and retrospectively assessed hospitalization data. The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians' availability, lack of acquaintance of on-call physicians with the residents, and health professionals' lack of knowledge about the residents' wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.

Quality of Care for Residents Dying in Ontario Long-Term Care Facilities: Findings from a Survey of Directors of Care

The purpose of this study was to collect information on the practice of end-of-life (EOL) care in long-term care (LTC) facilities in the Province of Ontario, Canada. A cross-sectional survey of directors of care in all licensed LTC facilities in the province was conducted between September 2003 and April 2004. Directors of care from 426 (76% response rate) facilities completed the postal survey questionnaire. The survey results identified communication problems between service providers and families, inadequate staffing levels to provide quality care to dying residents, and the need for training to improve staff skills in providing EOL care. Directors of care endorsed the use of a number of strategies that would improve the care of dying residents. Logistic regression analysis identified the eight most important items predictive of facility staff having the ability to provide quality EOL care. The findings contribute to the current discussion on policies for meeting the care needs of residents in LTC facilities until life's end.

The Last Word: Family Members’ Descriptions of End-of-Life Care in Long-Term Care Facilities

A postal survey was used to collect data from family members of deceased residents of six long-term care (LTC) facilities in order to explore end-of-life (EOL) care using the Family Perception of Care Scale. This article reports on the results of thematic analysis of family member comments provided while completing the survey. Family comments fell into two themes: 1) appreciation for care and 2) concerns with care. The appreciation for care theme included the following subthemes: psychosocial support, family care, and spiritual care. The concerns with care theme included the subthemes: physical care, staffing levels, staff knowledge, physician availability, communication, and physical environment. This study identified the need for improvement in EOL care skills among LTC staff and attending physicians. As such, there is a need to implement continuing education to address these issues.

End-of-Life Culture Change Practices in U.S. Nursing Homes in 2016/2017

CONTEXT

The nursing home (NH) culture change (CC) movement, which emphasizes person-centered care, is particularly relevant to meeting the unique needs of residents near the end of life.

OBJECTIVES

We aimed to evaluate the NH-reported adoption of person-centered end-of-life culture change (EOL-CC) practices and identify NH characteristics associated with greater adoption.

METHODS

We used NH and state policy data for 1358 NHs completing a nationally representative 2016/17 NH Culture Change Survey. An 18-point EOL-CC score was created by summarizing responses from six survey items related to practices for residents who were dying/had died. NHs were divided into quartiles reflecting their EOL-CC score, and multivariable ordered logistic regression was used to identify NH characteristics associated with having higher (quartile) scores.

RESULTS

The mean EOL-CC score was 13.7 (SD = 3.0). Correlates of higher scores differed from those previously found for non-EOL-CC practices. Higher NH leadership scores and nonprofit status were consistently associated with higher EOL-CC scores. For example, a three-point leadership score increase was associated with higher odds of an NH performing in the top EOL-CC quartile (odds ratio [OR] = 2.0, 95% CI: 1.82-2.30), whereas for-profit status was associated with lower odds (OR = 0.7, 95% CI: 0.49-0.90). The availability of palliative care consults was associated with a greater likelihood of EOL-CC scores above the median (OR = 1.5, 95% CI: 1.10-1.93), but not in the top or bottom quartile.

CONCLUSION

NH-reported adoption of EOL-CC practices varies, and the presence of palliative care consults in NHs explains only some of this variation. Findings support the importance of evaluating EOL-CC practices separately from other culture change practices.

Community-based palliative care is associated with reduced emergency department use by people with dementia in their last year of life: A retrospective cohort study

OBJECTIVE

To describe patterns in the use of hospital emergency departments in the last year of life by people who died with dementia and whether this was modified by use of community-based palliative care.

DESIGN

Retrospective population-based cohort study of people in their last year of life. Time-to-event analyses were performed using cumulative hazard functions and flexible parametric proportional hazards regression models.

SETTING/PARTICIPANTS

All people living in Western Australia who died with dementia in the 2-year period 1 January 2009 to 31 December 2010 (dementia cohort; N = 5261). A comparative cohort of decedents without dementia who died from other conditions amenable to palliative care (N = 2685).

RESULTS

More than 70% of both the dementia and comparative cohorts attended hospital emergency departments in the last year of life. Only 6% of the dementia cohort used community-based palliative care compared to 26% of the comparative cohort. Decedents with dementia who were not receiving community-based palliative care attended hospital emergency departments more frequently than people receiving community-based palliative care. The magnitude of the increased rate of emergency department visits varied over the last year of life from 1.4 (95% confidence interval: 1.1-1.9) times more often in the first 3 months of follow-up to 6.7 (95% confidence interval: 4.7-9.6) times more frequently in the weeks immediately preceding death.

CONCLUSIONS

Community-based palliative care of people who die with or of dementia is relatively infrequent but associated with significant reductions in hospital emergency department use in the last year of life.

Remaining in the nursing home versus transfer to acute care: resident, family, and staff preferences

Resident and family insistence on transfer is a major factor in the occurrence of potentially avoidable transfers from nursing homes (NHs) to acute care. The purpose of this study was to explore resident, family, and staff preferences regarding transfer to acute care. A sample of 271 NH residents, family members, staff, and medical providers were interviewed. Seventy-seven percent of residents reported that they had not given any thought to the question of whether they would want to be transferred to acute care. Family members wanted more information than residents, but more residents (39%) thought they should be fully involved in the transfer decision than their family members (12%) or staff (12%). Staff preferred keeping residents in the NH. Families were divided between transferring residents and having them remain in the NH. More residents indicated that their desire to transfer would depend on the severity of their condition and their prognosis. Ethnic group differences were noted. Results suggest that discussion of this issue should occur soon after admission and that differences in perspectives may be expected from those involved.

Variables correlated with elderly referral from nursing homes to general hospitals

Background

Referring patients from nursing homes to general hospitals exposes them to nosocomial diseases, and may result in the development of a broad spectrum of physical, mental and social damages. Therefore, minimizing the referring of nursing home patients to hospitals is an important factor for keeping the elderly healthy and minimizing health expenditures. In this study we examined the variables related to the referral rates from nursing homes to general hospitals and the relationship between the referral and the mortality rates among the elderly who live in nursing homes in the Haifa Sub-district.

Methods

Thirty-two nursing homes were included in a cross-sectional study. All medical directors and head nurses were interviewed using a structured questionnaire between November 2006 and October 2007. Statistical analysis, including the ANOVA and the nonparametric Spearman tests, were employed to determine the factors that influence referral rates and the correlation between referral rates and mortality rates.

Results

The referral rate ranged between 18 and 222 per 100 financed elderly in a single year. In the multivariate analysis, the absence of a physician from the nursing home at the time of the referral to general hospitals was the only significant variable related to referral rates. No significant relationships were found between referral rates and mortality rates.

Conclusions

Absence of a significant relationship between referral rates and mortality rates may indicate that high referral rates do not necessarily protect the elderly from death. Therefore, any recommendations issued by the Ministry of Health (MOH) should emphasize in-house treatment rather than hospitalization. Clear instructions on referral from nursing homes to general hospitals need to be constructed by the MOH. The MOH should increase the presence of physicians in the nursing homes, especially, when the need to refer a patient arises. Further quantitative and epidemiologic studies should be conducted in order to, more fully and reliably, create guidelines for policy recommendations.

Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations

OBJECTIVES

To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH.

DESIGN

Retrospective.

SETTING

Hospitalizations originating from NHs.

PARTICIPANTS

Long-term care NH residents who died in 2007.

MEASUREMENTS

A risk-adjusted QM was constructed for PAH. A Poisson regression model was used to predict the count of PAH given residents' risk factors. For each facility, the QM was defined as the difference between the observed facility-specific rate (per 1,000 person-years) of PAH (O) and the expected risk-adjusted rate (E). A logistic regression model with state fixed-effects was then fit to examine the association between facility characteristics and the likelihood of having higher-than-expected rates of PAH (O-E > 0). QM values greater than 0 indicate worse-than-average quality.

RESULTS

Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services.

CONCLUSION

Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life.

Site of death among nursing home residents in the United States: changing patterns, 2003-2007

CONTEXT

The proportion of US deaths occurring in nursing homes (NHs) has been increasing in the past 2 decades and is expected to reach 40% by 2020. Despite being recognized as an important setting in the provision of end-of-life (EOL) care, little is known about the quality of care provided to dying NH residents. There has been some, but largely anecdotal evidence suggesting that many US NHs transfer dying residents to hospitals, in part to avoid incurring the cost of providing intensive on-site care, and in part because they lack resources to appropriately serve the dying residents. We assessed longitudinal trends and geographic variations in place of death among NH residents, and examined the association between residents' characteristics, treatment preferences, and the probability of dying in hospitals.

METHODS

We used the Minimum Data Set (NH assessment records), Medicare denominator (eligibility) file, and Medicare inpatient and hospice claims to identify decedent NH residents. In CY2003-2007, there were 2,992,261 Medicare-eligible NH decedents from 16,872 US Medicare- and/or Medicaid-certified NHs. Our outcome of interest was death in NH or in a hospital. The analytical strategy included descriptive analyses and multiple logistic regression models, with facility fixed effects, to examine risk-adjusted temporal trends in place of death.

FINDINGS

Slightly more than 20% of decedent NH residents died in hospitals each year. Controlling for individual-level risk factors and for facility fixed effects, the likelihood of residents dying in hospitals has increased significantly each year between 2003 through 2007.

CONCLUSIONS

This study fills a significant gap in the current literature on EOL care in US nursing homes by identifying frequent facility-to-hospital transfers and an increasing trend of in-hospital deaths. These findings suggest a need to rethink how best to provide care to EOL nursing home residents.

Hospice utilization in nursing homes: association with facility end-of-life care practices

OBJECTIVES

Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay.

DESIGN

The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey).

SETTING AND PARTICIPANTS

In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study.

MEASUREMENTS

We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims.

RESULTS

The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death.

CONCLUSION

Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.

Advance directive discussions: lost in translation or lost opportunities?

BACKGROUND

Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness.

METHODS

This was a prospective observational cohort study of 458 adults admitted to the general medical services of a safety net hospital, an academic medical center, and a Veterans' Affairs (VA) hospital. Patients were asked if they had discussed advance directives, and we reviewed medical records for documented advance directives.

RESULTS

Overall, 45% of patients reported having had a discussion about advance directives (29% of Latinos compared with 54% of Caucasians, p=0.0002) and 24% of patients had a completed advance directive in their medical record (25% Latinos and 26% of Caucasians, p=not significant [ns]). Using logistic regression modeling and adjusting for socioeconomic status (SES), education level, and language spoken, Latinos (odds ratio [OR] 0.42, confidence interval [CI] 0.24-0.75) were less likely to report having advance directive discussions compared with Caucasians (referent). However, modeling of a completed advance directive in the medical record showed no significant difference between Latinos (OR 1.44, CI 0.73-2.85) and Caucasians (referent).

CONCLUSIONS

The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie.

The living-dying interval in nursing home-based end-of-life care: family caregivers' experiences

Guided by concepts from the living-dying interval ( Pattison, 1977 ) this study sought to explore family members' experiences with a dying nursing home resident. In-depth interviews were conducted with 31 caregivers of residents who had died. Interviews were audiotaped and transcribed. Themes that illuminated families' experiences on the living-dying interval were: an acute medical crisis (trigger events, accumulation of stressors, level of care crisis); the living-dying phase (advance care planning, hospitalization, end-stage decisions); and the terminal phase (beginning of the end, awareness of dying). The results illustrate critical periods for social work intervention with families of dying nursing home residents.

Decisions about transferring nursing home residents to hospital: highlighting the roles of advance care planning and support from local hospital and community health services

AIMS AND OBJECTIVES

To explore current practice and opportunities to improve practice in decision-making about transfer of nursing home residents to hospital.

BACKGROUND

Nursing home staff are often faced with the decision of whether to send a resident to hospital for medical treatment. While many residents will benefit from going to hospital, there are also several risks associated with this. This study sought to add to the existing body of research on this issue by seeking the views of nursing home managers, who are the persons most frequently involved in making these decisions.

DESIGN

Qualitative design using purposive, quota sampling.

METHOD

Qualitative interviews with 41 nursing home managers from south-western Sydney, Australia.

RESULTS

Factors affecting the decision to transfer a resident to hospital include acuteness of their condition; level and style of medical care available; role of family members; numbers, qualifications and skills mix of staff; and concern about criticism for not transferring to hospital. Two factors that have not featured as strongly in previous research are the roles of advance care planning and support from local hospital and community health services.

CONCLUSION

While transferring a nursing home resident to hospital is often necessary, there are many situations where they could be cared for in the nursing home; therefore, avoid complications associated with being in hospital. Apart from a range of factors already identified in the literature, this study has highlighted the important role that advance care planning and support from local health services can play in reducing unnecessary transfers to hospital.

RELEVANCE TO CLINICAL PRACTICE

There are several strategies that nursing homes and local health authorities can adopt to promote advance care planning and build better support systems between the two sectors, thereby reducing the numbers of residents who need to be transferred to hospital for their health care.

The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review

BACKGROUND

Dementia is a progressive and incurable disease which presents many challenges to care providers, particularly in terms of end-of-life care. A palliative approach; that is an approach to care which seeks to ease burdensome symptoms without attempting curative treatment, has been suggested as the most appropriate framework for addressing the needs of these people.

OBJECTIVES

The overall objective was to establish best practice in relation to palliative care for people with advanced dementia in terms of effectiveness and appropriateness.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished English language studies, published between 1997 and 2009. A three-step search strategy was utilised in each component of this review.

CRITICAL APPRAISAL

Quantitative, qualitative and discursive text articles were included in this review. Articles were assessed for congruence to the review criteria and then critically appraised for quality using the appropriate JBI tool.

DATA COLLECTION AND ANALYSIS

Data were extracted using the appropriate JBI data extraction tool for each methodology. No quantitative meta-analysis was possible due to clinical and statistical heterogeneity. Qualitative synthesis was performed with the JBI QARI tool. Discursive textual synthesis was performed with the JBI NOTARI tool.

RESULTS

Quantitative studies recommended the use of do not resuscitate, do not hospitalise orders and other forms of advance directives to prevent interventions unwanted by the patient and/or their family. Feeding tubes and the use of intravenous antibiotics were not found to be an effective intervention. Interventions designed to treat the burdensome symptoms of advanced dementia (such as pain and agitation) were found to be of the most benefit to patients.Qualitative analysis found it distressing for families to discuss or plan for, a poor quality of life for their loved one during the process of dying. Decisions concerned with palliative treatment for the person with advanced dementia were found to be complicated by knowledge differences, lack of understanding of the disease trajectory of dementia, the unpredictable nature of dementia itself and religious and socio-economical issues. Textual analysis found that a palliative approach to end of life care in advanced dementia is both appropriate and effective in terms of benefit to patients and their significant others.Despite the large volume of data retrieved and analysed for this review, no studies examining the role of case-conferencing for managing the introduction of palliative care or managing a palliative approach met the inclusion criteria for this systematic review.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR FUTURE RESEARCH: There is a need for further studies in the area of palliation and advanced dementia, particularly high quality studies investigating palliative care case conferencing and other methods of arranging and planning end of life care for people with dementia.

CONCLUSION

There is some evidence to suggest that a palliative approach is both effective and appropriate for use with people who have advanced dementia. There is no evidence for or against the use of case-conferencing as a method of arranging care for people with advanced dementia.

A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem

OBJECTIVES

To determine whether outcomes have changed over time for a managed, systematic approach to advance care planning (ACP).

DESIGN

Retrospective comparison of medical record and death certificate data of adults who died over a 7-month period in 2007/08 with those of adults who died over an 11-month period in 1995/96.

SETTING

All healthcare organizations in La Crosse County, Wisconsin.

PARTICIPANTS

Five hundred forty adults who died in 1995/96 and 400 adults who died in 2007/08.

INTERVENTION

A systematic ACP approach, Respecting Choices, collaboratively implemented in 1993 and continuously improved in subsequent years.

MEASUREMENTS

Demographic and cause-of-death data were collected from death certificates. Type and content of any advance directive (AD), existence and content of Physician Orders for Life-Sustaining Treatment, and medical treatment provided at the location of death in the last 30 days of life were abstracted from the medical record.

RESULTS

The recent data show a significantly greater prevalence of ADs (90% vs 85%, P=.02) and of availability of these directives in the medical record at the time of death (99.4% vs 95.2%, P<.001) than the data collected over 10 years ago. The new data suggest that quality efforts have improved the prevalence, clarity, and specificity of ADs.

CONCLUSION

A system for ACP can be managed in a geographic region so that, at the time of death, almost all adults have an advance care plan that is specific and available and treatment is consistent with their plan.

The needs, current knowledge, and attitudes of care staff toward the implementation of palliative care in old age homes

This study aims to explore in depth the needs, current knowledge, and attitudes of all ranks of old age home staff. A large-scale qualitative study with 13 semistructured focus groups was conducted in Hong Kong. Key themes were extracted by framework analysis. Three major themes were extracted, including role as a service provider, current knowledge, and attitude toward palliative care. There was a marked difference in familiarity with the concept of ''palliative care'' between different groups of staff, yet both shared the motivation for enhancement. The biggest concerns for the staff were elderly residents' readiness to accept palliative care, manpower, and resources. Care staff, regardless of rank, seemed to welcome and be ready to adopt a palliative care approach in caring for old age home residents, though not without worries and concerns.

Hospitalizations at the end of life among long-term care residents

BACKGROUND

Concerns have been raised over transfers into acute care hospitals at the end of life. The objective of this study was to examine (a) the extent of and (b) factors related to hospitalization in the last 180 days before death among long-term care (LTC) residents.

METHODS

The study included all LTC residents from 60 facilities in the province of Manitoba, Canada, who died in 2003/04 (N = 2,379), with data derived from administrative health care records. Multilevel regression analyses were conducted to examine the relationship between resident and facility characteristics and the following: location of death (in hospital vs the LTC facility); whether individuals were hospitalized in the last 180 days before death; and number of hospital days in the last 180 days.

RESULTS

Overall, 19.1% of LTC residents died in hospital; however, 40.7% were hospitalized at least once in the last 6 months before death. Several resident characteristics (age, trajectory group, and level of care) were related to the outcome measures. Living in a not-for-profit LTC facility decreased the odds of dying in hospital (adjusted odds ratio [OR] = 0.589; 95% confidence interval [CI] = 0.402-0.863) or being hospitalized (adjusted OR = 0.647; 95% CI = 0.452-0.926).

CONCLUSIONS

Hospitalization at the end of life is common among LTC residents, and the likelihood of hospital transfers is increased for residents who are younger, have organ failure, lower care level needs, as well as among those who live in for-profit facilities. Particular emphasis should, therefore, be placed on targeting these groups to determine the appropriateness of hospital admission and possible ways of reducing transfers.

Palliative care for people with Alzheimer's disease

The task of aligning the philosophical and clinical perspectives on ethics is a challenging one. Clinical practice informs philosophy, not merely by supplying cases, but through shaping and testing philosophical concepts in the reality of the clinical world. In this paper we explore several aspects of the relationship between the philosophical and the clinical within a framework of palliative care for people living with Alzheimer's disease. We suggest that health professionals have a moral obligation to question previous assumptions concerning the quality of life among people with Alzheimer's, and to address the question: does the concept of palliative care properly embrace people with severe dementia? We propose an ethic of palliative care for people with Alzheimer's that is based, not on the traditionally understood principle of autonomy, but on the need to listen to those living with the disease, acknowledging their profound loss of cognitive abilities, with a focus on preventing and relieving suffering, and improving the individual's quality of life.

Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: the CareAD Study

BACKGROUND

Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.

METHODS

The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery).

RESULTS

Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a 'do not hospitalize' order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity.

CONCLUSIONS

Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.

Clinical problems at the end of life in a Swedish population, including the role of advancing age and physical and cognitive function

Aims: To improve the understanding of specific clinical problems at the end of life, including the role of advancing age, physical function and cognitive function. Methods: The study is part of an explorative survey of data relevant to end-of-life healthcare services during the last 3 months of life of a randomly selected sample of the population of a Swedish county. Data were selected through retrospective reviews of death certificates and medical records, and comprise information from 12 municipalities and 229 individuals. Results: A range of prevalent concerns was found. Overall deterioration, urinary incontinence, constipation, impaired skin integrity, anxiety and sleep disturbances were significantly associated with dependency on others for activities of daily living; pulmonary rattles and swallowing disturbances were associated with cognitive disorientation; excepting cough, advancing age did not have significant impacts on these prevalent clinical concerns. Conclusions: A range of distressing conditions constitute a common pathway for many individuals at or near the end of life. The incorporation of health promotion as a principle of palliative care will probably benefit individuals at the end of life, and includes a proactive focus and emphasis on enhanced well-being at the time of diagnosis of a life-threatening illness. For individuals with physical and cognitive limitations imparting a state of dependency, it is reasonable to provide assurance of care for individuals' specific needs by professionals with both training for and competence in this special and sometimes unique clinical environment.

Utilization of health-care services at the end-of-life

End-of-life care poses a growing clinical and policy concern since most people who are dying utilize health-care services during this period of life. Hence, end-of-life care is a common and integral part of the care provided by health-care systems. There is a growing call for the implementation of a palliative approach as an integral part of all end-of-life care. The purpose of this study was thus to provide policy-makers, health-care providers and professional caregivers with increased knowledge about mainstream patterns of health-care utilization during end-of-life. The patterns of use of health-care services in a Swedish population who accessed the health-care system during their last 3 months of life were in this study examined through a retrospective examinations of medical and nursing records (n=229). We found high prevalences of use of both hospital care, primary care and care provided in people's homes and nearly three quarters of the persons included in the study used between two and three health-care services. However, the probability of using different health-care services was found to be strongly depending on demographic, social, functional and disease related characteristics. The study reveals a considerable use of different health-care services during end-of-life. It is hence essential to, on one hand delineate how such health-care services best can support people at the end-of-life, and on the other hand develop policies which facilitate the process of dying, both in hospitals as well as in peoples' homes. Implications for policy are discussed.

Health care consumption and place of death among old people with public home care or in special accommodation in their last year of life

BACKGROUND AND AIMS

Developing care for older people in the last phase of life requires knowledge about the type and extent of care and factors associated with the place of death. The aim of this study was to examine age, living conditions, dependency, care and service among old people during their last year of life, but also their place of death and factors predicting it.

METHODS

The sample (n=1198) was drawn from the care and services part of the Swedish National Study on Ageing and Care (SNAC). Criteria for inclusion were being 75+ years, dying in 2001-2004, and having public care and services at home or in special accommodation.

RESULTS

In the last year of life, 82% of persons living at home and 51% living in special accommodation were hospitalized; median stays were 10 and 6.7 days respectively. Those living at home were younger and less dependent in ADL than those living in special accommodation. Those living at home and those having several hospital stays more often died in hospital. In the total sample, more visits to physicians in outpatient care predicted dying in hospital, whereas living in special accommodation and PADL dependency predicted dying outside hospital.

CONCLUSIONS

Old people in their last year of life consumed a considerable amount of both municipal care and outpatient and in-hospital medical care, especially those living at home, which in several cases ended with death in hospital.

Physician Communication with Family Caregivers of Long-Term Care Residents at the End of Life

OBJECTIVES

To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions.

DESIGN

Retrospective study of family caregivers of persons who died in LTC.

SETTING

Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities.

PARTICIPANTS

One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death.

MEASUREMENTS

Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96).

RESULTS

Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities.

CONCLUSION

Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

Quality of Care in a Veterans Affairs' Nursing Home-Based Hospice Unit

OBJECTIVES

To report on quality of care in a Veterans Affairs (VA) dedicated hospice unit.

DESIGN

Mortality follow-back survey of bereaved family members, using a quality of care instrument.

SETTING

A VA inpatient hospice unit.

PARTICIPANTS

Bereaved family members.

MEASUREMENTS

Satisfaction with care as perceived by family members using a telephone survey.

RESULTS

159 family members were contacted with 102 completing full and 37 completing abbreviated surveys. (Overall response rate: 87.4%, complete responses: 64.2%) 98% of all respondents reported overall quality of care as Excellent or Very Good.

CONCLUSION

High levels of satisfaction were reported by family members. Implications of this initiative for the provision of hospice care in nursing homes are discussed, including replication of the model in both VA and non-VA nursing home settings.

Predicted survival vs. actual survival in terminally ill noncancer patients in Dutch nursing homes

Studies on the prediction of survival have mainly focused on hospital and hospice patients suffering from cancer. The aim of this study was to describe the predicted vs. the actual survival in terminally ill, mainly noncancer patients in Dutch nursing homes (NHs). A prospective cohort study was conducted in 16 NHs representative for The Netherlands. A total of 515 NH patients with a maximum life expectancy of 6 weeks, as assessed by an NH physician, were included. NH physicians were accurate in more than 90% of their prognoses for terminally ill--mainly noncancer--NH patients, when death occurred within 7 days. For a longer period of time, their predictions became inaccurate. In the category of patients who were expected to die within 8-21 days, predictions were accurate in 16.0%, and in the category of patients expected to die within 22-42 days, this was 13.0%. Predictions in these categories were mainly optimistic (patient died earlier) in 68.6% and 52.2%, respectively. The findings of this study suggest that accurate prediction of survival of (mainly) noncancer patients in NHs is only possible when death is imminent and seems to be dependent on an intimate knowledge of patients. Prognostication over a longer period of time tends to be less accurate, and, therefore, continues to be a challenging task for NH physicians.

The Turning Point: Clinical Identification of Dying and Reorientation of Care

Palliative care is increasingly organized within the setting of formal health care systems but the demarcation has become unclear between, on the one hand, care directed at cure and rehabilitation and palliative care aimed at relief of suffering on the other. With the purpose to increase the understanding about the turning point reflecting identification of dying and reorientation of care, this study explores this phenomenon as determined from health care records of a representative sample (n = 229). A turning point was identified in 160 records. Presence of circulatory diseases, sporadic confinement to bed, and deterioration of condition had a significant impact upon the incidence of such turning point. The time interval between the turning point and actual death ranged between one and 210 days. Thirty percent of these turning points were documented within the last day of life, 33% during the last 2-7 days, 19.5% during the last 8-30 days, 13% during the last 31-90 days, and 4.5% during the last 91-210 days of life. The time interval between the turning point and actual death was significantly longer among individuals with neoplasm(s) and significantly shorter among individuals suffering from musculoskeletal diseases. Perhaps this reflects a discrepancy between the ideals of palliative care, and a misinterpretation of the meaning of palliative care in everyday clinical practice. The findings underscore that improvement in timing of clinical identification of dying and reorientation of care will likely favour a shift from life-extending care to palliative care.

Family perspectives on end-of-life care experiences in nursing homes

PURPOSE

The purpose of this study is to expand knowledge regarding end-of-life care received in nursing homes through the use of narrative interviews with family members close to the decedents.

DESIGN AND METHODS

We conducted follow-up qualitative interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants. Interviews were taped and transcribed and then coded by a five-member, multidisciplinary team to identify overarching themes.

RESULTS

Respondents report that the needs of dying patients are often insufficiently addressed by health care professionals. Their low expectations of nursing homes and their experiences cause many to become vigilant advocates. Respondents report that physicians are often "missing in action," and they desire more and better trained staff. They indicate that regulations reinforce task-focused rather than person-centered care and add to patient and family burden. Although hospice services are reported to enhance end-of-life care, respondents also report late referrals and occasional misunderstandings about the role and scope of hospice.

IMPLICATIONS

Sustained efforts on many fronts are needed to improve end-of-life care in nursing homes. Policy recommendations are suggested.

Recent trends in advance directives at nursing home admission and one year after admission

PURPOSE

Advance directives are important planning and decision-making tools for individuals in nursing homes.

DESIGN AND METHODS

By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission.

RESULTS

The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type.

IMPLICATIONS

The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time.

The challenge of providing palliative care in the nursing home: part 1 external factors

One impact of the baby boom generation and improved medical care is that nursing homes will be the place of care and site of death for growing numbers of frail, older persons dying of chronic progressive illnesses. The nursing home settings may appear to be an appropriate environment wherein residents could receive palliative care, but the literature suggests that provision of such care is replete with challenge. Some of these challenges are external to the nursing home environment and are beyond the setting's control, others have internal origins and to some extent may be under the home's control. In part I of this two-part article, we review and critically analyse the primary external factors identified in the literature -- characteristics of the residents -- as they impact on the ability of care homes to deliver palliative care.

Dispelling Myths About Palliative Care and Older Adults

OBJECTIVES

To explore the myths about palliative care and older adults with cancer.

DATA SOURCES

Research literature and review articles.

CONCLUSION

Several myths about older adults exist: older adults are the same as younger adults, older adults are all the same, and optimizing function and quality of life are not important outcomes. Little research has focused on older adults receiving palliative care and their families.

IMPLICATIONS FOR NURSING PRACTICE

The Oncology Nursing Society and Geriatric Oncology Consortium published the Joint Position Statement on Cancer Care in Older Adults acknowledging the unique needs of older adults with cancer. Application of this statement may be helpful in guiding inquiry and practice in the care for older adults receiving palliative care.