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Gonella S, Campagna S, Dimonte V. A Situation-Specific Theory of End-of-Life Communication in Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:869. [PMID: 36613191 PMCID: PMC9820248 DOI: 10.3390/ijerph20010869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/01/2022] [Accepted: 12/13/2022] [Indexed: 06/17/2023]
Abstract
High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.
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Affiliation(s)
- Silvia Gonella
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
| | - Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
| | - Valerio Dimonte
- Direction of Health Professions, City of Health and Science University Hospital of Torino, Corso Bramante 88-90, 10126 Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, Via Santena 5 bis, 10126 Turin, Italy
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2
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Falzarano F, Cimarolli VR, Minahan J, Horowitz A. Long-Distance Caregivers: What are Their Experiences with Formal Care Providers? Clin Gerontol 2022; 45:1273-1284. [PMID: 32589110 PMCID: PMC7762738 DOI: 10.1080/07317115.2020.1783043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Extensive literature has documented the experiences of informal caregivers and their interactions with formal care providers, yet this research is almost entirely limited to caregivers who live near their care-recipients. This study aims to describe long-distance caregivers' (LDC) experiences (e.g., satisfaction and challenges) with formal care providers. Subgroup differences were examined based on the care-recipient's (CR) dementia status and residential setting (community versus residential care). METHODS Data were collected from 296 LDCs (Mage = 56.64, SD = 12.40) categorized into four subgroups based on CR dementia status and residential setting. Participants rated their overall satisfaction, satisfaction with communication and information, and described challenges faced in their interactions with formal care providers. RESULTS Challenges related to formal care providers were significantly greater and satisfaction significantly lower among LDCs of CRs in residential care, irrespective of dementia status, when compared to LDCs of CRs in the community. CONCLUSIONS This study provides insights into the experiences of a growing segment of the caregiver population managing care from a distance, specifically in their interactions with formal care providers. CLINICAL IMPLICATIONS The results of this study point to the possible necessity for the development of novel interventions to improve and enhance communication and collaboration between FCPs and informal caregivers.
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Affiliation(s)
- Francesca Falzarano
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Verena R Cimarolli
- LeadingAge LTSS Center @UMass Boston, Washington, District of Columbia, USA
| | - Jillian Minahan
- Psychology Department, Fordham University, Bronx, New York, USA
| | - Amy Horowitz
- Graduate School of Social Services, Fordham University, New York, New York, USA
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3
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Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia. Nurs Clin North Am 2022; 57:259-271. [DOI: 10.1016/j.cnur.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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4
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Yildiz B, Korfage IJ, Witkamp EF, Goossensen A, van Lent LG, Pasman HR, Onwuteaka-Philipsen BD, Zee M, van der Heide A. Dying in times of COVID-19: Experiences in different care settings - An online questionnaire study among bereaved relatives (the CO-LIVE study). Palliat Med 2022; 36:751-761. [PMID: 35264024 PMCID: PMC9006387 DOI: 10.1177/02692163221079698] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The COVID-19 pandemic and restricting measures have affected end-of-life care across different settings. AIM To compare experiences of bereaved relatives with end-of-life care for a family member or friend who died at home, in a hospital, nursing home or hospice during the pandemic. DESIGN An open observational online survey was developed and disseminated via social media and public fora (March-July 2020). Data were analyzed using descriptive statistics and logistic regression analyses. PARTICIPANTS Individuals who lost a family member or friend in the Netherlands during the COVID-19 pandemic. RESULTS The questionnaire was filled out by 393 bereaved relatives who lost a family member or friend at home (n = 68), in a hospital (n = 114), nursing home (n = 176) or hospice (n = 35). Bereaved relatives of patients who died in a hospital most often evaluated medical care (79%) as sufficient, whereas medical care (54.5%) was least often evaluated as sufficient in nursing homes. Emotional support for relatives was most often evaluated as sufficient at home (67.7%) and least often in nursing homes (40.3%). Sufficient emotional support for relatives was associated with a higher likelihood to rate the place of death as appropriate. Bereaved relatives of patients who died at a place other than home and whose care was restricted due to COVID-19 were less likely to evaluate the place of death as appropriate. CONCLUSION End-of-life care during the COVID-19 pandemic was evaluated least favourably in nursing homes. The quality of emotional support for relatives and whether care was restricted or not were important for assessing the place of death as appropriate.
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Affiliation(s)
- Berivan Yildiz
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ida J Korfage
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erica Fe Witkamp
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Research Centre Innovations in Care, University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Liza Gg van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - H Roeline Pasman
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Masha Zee
- Department of public and occupational health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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Aschieri F, Barello S, Durosini I. "Invisible Voices": A Critical Incident Study of Family Caregivers' Experience of Nursing Homes After Their Elder Relative's Death. J Nurs Scholarsh 2020; 53:65-74. [PMID: 33206459 DOI: 10.1111/jnu.12610] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The literature provides few examples of family caregivers' retrospective evaluation of nursing home services. This study aimed at analyzing narratives of Italian family caregivers of elders who experienced nursing home placement. DESIGN AND METHODS Data were gathered through in-depth interviews with family members after their relatives' death. The interviews were based on the Critical Incident Technique, which allowed the categorization of the most memorable positive and negative events from the perspective of family members of elders deceased in nursing homes. Interviews were interpreted with a phenomenologically inspired thematic analysis approach. Participants were screened for complicated grief disorder as a confounding variable in relatives' accounts of the treatment. RESULTS Results suggested that positive long-term recollection of the nursing home was associated with different themes emerging from the interviews: medical reliability and expertise, active demonstrations of care that extend beyond the contract with the facility, individualized attention, responsiveness, openness to dialog with family members about routines, management of the first impression, and family engagement. Lack of professionals' expertise and medical failures, lack of care for patients' personal goods, lack of family involvement, lack of individualized attention, lack of responsiveness, poor patient surveillance, and structural limits of the facilities were the themes that were more frequently negatively associated with the nursing home experience. IMPLICATIONS FOR PRACTICE Focusing on the key dimensions connected to the quality of the experience of family members can enrich the quality of existing nursing home services and allow healthcare policymakers and managers to design better facilities for the patients.
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Affiliation(s)
- Filippo Aschieri
- Associate Professor, European Center for Therapeutic Assessment; Department of Psychology, Università Cattolica del Sacro Cuore, Milano, Lombardia, Italy
| | - Serena Barello
- Assistant Professor, EngageMinds Hub, Consumer, Food & Health Engagement Research Center; Department of Psychology, Università Cattolica del Sacro Cuore, Milano, Lombardia, Italy
| | - Ilaria Durosini
- Research fellow, Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Ryskina KL, Foley KA, Karlawish JH, Uy JD, Lott B, Goldberg E, Hodgson NA. Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities. BMC Geriatr 2020; 20:463. [PMID: 33172392 PMCID: PMC7653446 DOI: 10.1186/s12877-020-01869-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the US, post-acute care in skilled nursing facilities (SNFs) is common and outcomes vary greatly across facilities. Little is known about the expectations of patients and their caregivers about physician care during the hospital to SNF transition. Our objectives were to (1) describe the experiences and expectations of patients and their caregivers with SNF physicians in SNFs, and (2) identify patterns that differed between patients with vs. without cognitive impairment. METHODS This qualitative study used grounded theory approach to analyze data collected from semi-structured interviews at five SNFs in January-August 2018. Patients admitted for short-term SNF care 5-10 days prior were eligible to participate. Thematic analysis was performed to detect recurrent themes with a focus on modifiable aspects of physician care. Analysis was stratified by patient cognitive impairment (measured by the Montreal Cognitive Assessment at the time of the interview). RESULTS Fifty patients and six caregivers were interviewed. Major themes were: (1) patients had poor awareness of the physician in charge of their care; (2) they were dissatisfied with the frequency of interaction with the physician; and (3) participants valued the perception of receiving individualized care from the physician. Less cognitively impaired patients were more concerned about limited interactions with the physicians and were more likely to report attempts to seek out the physician. CONCLUSION Patient and caregiver expectations of SNF physicians were not well aligned with their experiences. SNFs aiming to improve satisfaction with care may focus efforts in this area, such as facilitating frequent communication between physicians, patients and caregivers.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Kierra A Foley
- Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jason H Karlawish
- Division of Geriatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua D Uy
- Division of Geriatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Briana Lott
- VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA
| | - Erica Goldberg
- Department of Emergency Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy A Hodgson
- Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Sedhom R, Kuo PL, Gupta A, Smith TJ, Chino F, Carducci MA, Bandeen-Roche K. Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities? J Geriatr Oncol 2020; 12:361-367. [PMID: 33121909 DOI: 10.1016/j.jgo.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Place of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer. METHODS Deidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. RESULTS From 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%. CONCLUSION Hospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America.
| | - Pei-Lun Kuo
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Thomas J Smith
- Department of Palliative Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Michael A Carducci
- Sidney Kimmel Comprehensive Cancer Center At Johns Hopkins, Baltimore, MD, United States of America
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, United States of America
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8
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What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences. Palliat Support Care 2020; 19:208-216. [PMID: 32830632 DOI: 10.1017/s1478951520000747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs. METHODS This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes. RESULTS FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care. SIGNIFICANCE OF RESULTS Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.
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Ryskina KL, Wang H, Foley KA, Merchant RM. Patient and Caregiver Perceptions of Nursing Home Physicians: Insight from Yelp Reviews, 2009-2018. J Am Geriatr Soc 2020; 68:2101-2105. [PMID: 32544277 DOI: 10.1111/jgs.16634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the content of reviews submitted on Yelp that pertain to nursing home (NH) physicians. DESIGN Retrospective qualitative study. SETTING NHs in the United States reviewed on Yelp from 2009 to 2018 with reviews that discussed NH physicians. PARTICIPANTS Physicians in 375 NHs in 31 states. MEASUREMENTS Content analysis was performed to detect recurrent themes and divergent ideas about NH physicians perceived by reviewers. RESULTS Average rating among NHs with physician reviews was 2.0 (standard deviation = 1.5; range = 1-5). The major themes from content analysis of reviews that discussed physicians were perceived attitudes of clinicians toward patients and caregivers, physician communication with patients or caregivers, and perceived clinical expertise of the physicians. CONCLUSION Unsolicited online reviews of NHs that comment on patient and caregiver perceptions of physician care represent a small but growing number of online comments about NHs. These reviews contain important information about aspects of physician care valued by NH patients and caregivers. However, the sample of comments about physicians represents a small proportion of online reviews and is not representative of all NHs. As online reviews grow in number and become more representative, these data could be used by physicians to improve perceptions of their care by NH patients and their families, and by NHs to inform expectations of their medical director and attending physicians.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah Wang
- Jerome Fisher Program in Management and Technology, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kierra A Foley
- Hillman Scholar in Nursing Innovation at the University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Raina M Merchant
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Digital Health, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Emergency Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Westergren A, Behm L, Lindhardt T, Persson M, Ahlström G. Measuring next of kin's experience of participation in the care of older people in nursing homes. PLoS One 2020; 15:e0228379. [PMID: 32004352 PMCID: PMC6994140 DOI: 10.1371/journal.pone.0228379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/14/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Lack of conceptual clarity and measurement methods have led to underdeveloped efforts to measure experience of participation in care by next of kin to older people in nursing homes. OBJECTIVE We sought to assess the measurement properties of items aimed at operationalizing participation in care by next of kin, applied in nursing homes. METHODS A total of 37 items operationalizing participation were administered via a questionnaire to 364 next of kin of older people in nursing homes. Measurement properties were tested with factor analysis and Rasch model analysis. RESULTS The response rate to the questionnaire was 81% (n = 260). Missing responses per item varied between <0.5% and 10%. The 37 items were found to be two-dimensional, and 19 were deleted based on conceptual reasoning and Rasch model analysis. One dimension measured communication and trust (nine items, reliability 0.87) while the other measured collaboration in care (nine items, reliability 0.91). Items successfully operationalized a quantitative continuum from lower to higher degrees of participation, and were found to generally fit well with the Rasch model requirements, without disordered thresholds or differential item functioning. Total scores could be calculated based on the bifactor subscale structure (reliability 0.92). Older people (≥ 65 years) reported a higher degree of communication and trust and bifactor total scores than younger people (p < 0.05 in both cases). People with a specific contact person experienced a higher degree of participation in the two subscales and the bifactor total score (p < 0.05 in all three instances). CONCLUSION Psychometric properties revealed satisfactory support for use, in nursing home settings, of the self-reported Next of Kin Participation in Care questionnaire, with a bifactor structure. Additional research is needed to evaluate the effectiveness of the scales' abilities to identify changes after intervention. TRIAL REGISTRATION The KUPA project has Clinical Trials number NCT02708498.
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Affiliation(s)
- Albert Westergren
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Research Platform for Collaboration for Health, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
- * E-mail:
| | - Lina Behm
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Tove Lindhardt
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Internal Medicine, Copenhagen University Hospital, Herlev, Denmark
| | - Magnus Persson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Gonella S, Basso I, De Marinis MG, Campagna S, Di Giulio P. Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings. Palliat Med 2019; 33:589-606. [PMID: 30969160 DOI: 10.1177/0269216319840275] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase. AIM To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective. DESIGN Systematic review (PROSPERO no. 95581) with meta-aggregation method. DATA SOURCES Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied. RESULTS In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care. CONCLUSION The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.
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Affiliation(s)
- Silvia Gonella
- 1 Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy.,2 Azienda Ospedaliero Universitaria Città della Salute e della Scienza of Turin, Corso Bramante 88-90, 10126 Turin, Italy
| | - Ines Basso
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
| | - Maria Grazia De Marinis
- 4 Nursing Research Unit. University Campus Bio Medico of Rome, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Sara Campagna
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
| | - Paola Di Giulio
- 3 Department of Public Health and Pediatrics, University of Turin, via Santena 5 bis, 10126 Turin, Italy
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Raco M, Burdett T, Heaslip V. Exploring an integrated palliative care model for older people: an integrative review. JOURNAL OF INTEGRATED CARE 2019. [DOI: 10.1108/jica-10-2018-0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Due to an international ageing population, global health organisations have recognised the challenges arising from fragmented interaction between health and social sectors in the end of life care. The purpose of this paper is to explore the existing literature on integrative palliative care services for older people.
Design/methodology/approach
An integrative review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Papers included in the review focused upon integrated care within palliative care systems (January 2007–2017). A certain number of papers were excluded when the review focused on individuals younger than 65, not written in English and not being focused on integrated palliative care.
Findings
Nine studies fitted the inclusion criteria and three themes were identified: person-centred care, co-ordination of care, and education and training. The review identifies that integrated palliative care requires co-ordinated techniques that focus upon the quality of life, individual needs and awareness of vulnerability rather than fixation on inevitable mortality.
Research limitations/implications
The emerging presence of the need for integrated palliative care requires further research in order to develop coherent models of integrated palliative care which can be incorporated into practice.
Originality/value
This review identified themes relevant to the emerging issues in the global health sector of end of life care. The literature suggests that the optimised use of an integrated care approach to a palliative model of care is required and in need of further investigation.
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Gonella S, Basso I, Dimonte V, Martin B, Berchialla P, Campagna S, Di Giulio P. Association Between End-of-Life Conversations in Nursing Homes and End-of-Life Care Outcomes: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2019; 20:249-261. [PMID: 30470575 DOI: 10.1016/j.jamda.2018.10.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals-residents and health care professionals-family EOL conversations and EOL care outcomes. DESIGN Systematic review with meta-analysis. SETTING AND PARTICIPANTS Seven databases were searched in December 2017 to find studies that focused on health care professionals-residents (without oncologic disease) and health care professionals-family EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes. MEASURES Random effects meta-analyses with subsequent quality sensitivity analysis and meta-regression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias. RESULTS 16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionals-family EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio = 2.23, 95% confidence interval: 1.58-3.14). The overall effect of health care professionals-family EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the meta-regression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing life-sustaining treatments. No publication bias was detected (P = .4483). CONCLUSIONS/IMPLICATIONS This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decision-making process at EOL needs to be promoted.
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Affiliation(s)
- Silvia Gonella
- Department of Biomedicine and Prevention, University of Roma Tor Vergata, Roma, Italy; Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.
| | - Ines Basso
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy; Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Barbara Martin
- Research and Third Mission Area, University of Torino, Torino, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Sara Campagna
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
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14
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Ekström K, Spelmans S, Ahlström G, Nilsen P, Alftberg Å, Wallerstedt B, Behm L. Next of kin's perceptions of the meaning of participation in the care of older persons in nursing homes: a phenomenographic study. Scand J Caring Sci 2019; 33:400-408. [PMID: 30604875 PMCID: PMC7328681 DOI: 10.1111/scs.12636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/07/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Being involved in the care of a loved one is a desire of many next of kin. However, according to several studies of the perceptions of nursing home staff, the involvement of next of kin is not an obvious part of care. To be able to involve next of kin in care at nursing homes, the perceptions of what participation means are an important piece of knowledge. The aim of this study was therefore to describe variations in next of kin's perceptions of the meaning of participation in the care of older persons living in nursing homes. METHODS Eighteen next of kin of older persons living in ten nursing homes in Sweden were recruited for interviews. The study design was based on a phenomenographic approach, focusing on the qualitatively different ways in which a person perceives, experiences or conceptualises a phenomenon or certain aspect of reality. RESULTS Five categories emerged from analysis of the interviews, representing the next of kin's perceptions of the meaning of participation in the care of older persons in nursing homes: be present; communicate; monitor; do practical tasks; and to represent. The next of kin expressed meanings that belonged to more than one category, and the categories were interdependent. CONCLUSIONS Our results indicate that there are several meanings of next of kin's perceptions of participation at nursing homes. Nursing home staff's knowledge of these perceptions is important to enable next of kin to participate according to their own preferences.
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Affiliation(s)
- Kajsa Ekström
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
| | - Sanna Spelmans
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
| | - Gerd Ahlström
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden
| | - Åsa Alftberg
- Faculty of Health and Society, Department of Social Work, Malmö University, Malmö, Sweden
| | - Birgitta Wallerstedt
- Faculty of Health and Life Sciences, School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden.,Centre for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
| | - Lina Behm
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
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15
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Trotta RL, Boltz M, Happ MB, Strumpf N. Cultivating Knowing and Relationships: Nursing Assistants’ Interactions With Residents Receiving Palliative Care. ACTA ACUST UNITED AC 2018. [DOI: 10.20467/1091-5710.22.4.189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Nursing home residents are among the most vulnerable members of society. The literature emphasizes promotion of personhood, dignity, and comfort—dimensions that fall within the purview of the certified nursing assistant (CNA). Little is known about how CNAs approach caring for a dying resident. This grounded theory study explored CNA–resident interactions for residents receiving palliative care. The theory “Cultivating Knowing and Relationships” emerged, which represents a social–psychological process of how CNAs capitalize on reciprocity and achievement of gratification to develop personal relationships with residents and maintain personhood and dignity through death. These findings underscore CNAs’ significant role in enhancing quality.
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16
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Udo C, Neljesjö M, Strömkvist I, Elf M. A qualitative study of assistant nurses' experiences of palliative care in residential care. Nurs Open 2018; 5:527-535. [PMID: 30338098 PMCID: PMC6177554 DOI: 10.1002/nop2.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/16/2018] [Indexed: 01/20/2023] Open
Abstract
AIM To explore assistant nurses' experiences and perceptions of both positive and negative aspects of providing palliative care for older people in residential care facilities. DESIGN A qualitative explorative study. METHODS Critical incidents were collected through semi-structured face-to-face interviews and analysed by performing a qualitative content analysis. RESULTS A total of 40 critical incidents from daily work was described by assistant nurses. The results showed that close cooperation between unlicensed and licensed professionals was crucial to provide good care but was sometimes negatively affected by the organizational structure. The availability of professionals was identified as a critical factor in providing good care at the end of life in a consultative organization. The most prominent findings were those that indicated that, especially in a consultative organization, there seems to be a need for clear roles, comprehensive and clear care plans and a solid support structure to ensure continuity of care.
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Affiliation(s)
- Camilla Udo
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
- Center for Clinical Research DalarnaFalunSweden
| | - Maria Neljesjö
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
| | | | - Marie Elf
- School of Education, Health and Social StudiesDalarna UniversityFalunSweden
- Karolinska InstitutetDepartment of Neurobiology, Care Sciences and SocietyStockholmSweden
- Chalmers University of TechnologySchool of ArchitectureGothenburgSweden
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17
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Makaroun LK, Teno JM, Freedman VA, Kasper JD, Gozalo P, Mor V. Late Transitions and Bereaved Family Member Perceptions of Quality of End-of-Life Care. J Am Geriatr Soc 2018; 66:1730-1736. [PMID: 29972587 DOI: 10.1111/jgs.15455] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/21/2018] [Accepted: 04/25/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine associations between healthcare transitions at the end of life (EOL; late transitions) and bereaved family members' and friends' assessment of EOL quality of care (QOC). DESIGN National Health and Aging Trends Study (NHATS), a prospective cohort of Medicare enrollees aged 65 and older. SETTING United States, all sites of death. PARTICIPANTS Family members and close friends of decedents from NHATS Rounds 2 through 6 (N=1,653; weighted 6.0 million Medicare deaths). MEASUREMENTS Multivariable logistic regression with survey weights was used to examine the association between having a late transition and reports of perceived unmet needs for symptom management, spiritual support, concerns with communication, and overall QOC. RESULTS Seventeen percent of decedents had a late transition. Bereaved respondents for decedents experiencing late transitions were more likely to report that the decedent was treated without respect (21.3% vs 15.6%; adjusted odds ratio (AOR)=1.59, 95% confidence interval (CI)=1.09-2.33), had more unmet needs for spiritual support (67.4% v 55.2%; AOR=1.48, 95% CI=1.03-2.13), and were more likely to report they were not kept informed about the person's condition (31.0% vs 20.9%; AOR=1.54, 95% CI=1.07-2.23). Bereaved respondents were less likely to rate QOC as excellent when there was a late transition (43.6% vs 48.2%; AOR=0.79, 95% CI=0.58-1.06). Subgroup analyses of those experiencing a transition between a nursing home and hospital (13% of all late transitions) revealed such transitions to be associated with even worse QOC. CONCLUSION Transitions in the last 3 days of life are associated with more unmet needs, higher rate of concerns, and lower rating of QOC than when such late transitions are absent, especially when that transition is between a nursing home and hospital.
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Affiliation(s)
- Lena K Makaroun
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, Seattle, Washington.,Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington
| | - Joan M Teno
- Provisional Oregon Health and Science University, Portland, Oregon.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Vicki A Freedman
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Judith D Kasper
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Pedro Gozalo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Providence, Rhode Island
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18
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Harsányiová M, Prokop P. Living condition, weight loss and cognitive decline among people with dementia. Nurs Open 2018; 5:275-284. [PMID: 30062020 PMCID: PMC6056446 DOI: 10.1002/nop2.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/22/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS The aim of this study was to investigate cognitive performance and BMI of patients with dementia living in their own homes with family members, nursing homes and alone. DESIGN A prospective observational cohort study with a quantitative design. METHOD Mini-mental state examination (MMSE) scores and BMI were examined with a sample of Slovak patients (N = 428). Patients were followed up 12 months later after the first examination. RESULTS Cognitive decline was significantly faster for patients living in nursing homes and for solitary patients. BMI consistently decreased in the follow-up examination and this drop was stronger in patients living alone and in nursing homes. Patients with VaD manifested a stronger BMI decline as compared with AD patients. This study suggests that impoverished conditions such as nursing homes or social isolation of solitary people contribute to stronger progress in dementia. Healthcare professionals need to implement meaningful activities for institutionalized people and for people who are living alone to eliminate the negative impact of an impowerished environment on patient's cognitive functioning.
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Affiliation(s)
| | - Pavol Prokop
- Faculty of EducationDepartment of BiologyTrnava UniversityTrnavaSlovakia
- Institute of ZoologySlovak Academy of SciencesBratislavaSlovakia
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19
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Lavin K, Davydow DS, Downey L, Engelberg RA, Dunlap B, Sibley J, Lober WB, Okimoto K, Khandelwal N, Loggers ET, Teno JM, Curtis JR. Effect of Psychiatric Illness on Acute Care Utilization at End of Life From Serious Medical Illness. J Pain Symptom Manage 2017; 54:176-185.e1. [PMID: 28495487 DOI: 10.1016/j.jpainsymman.2017.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 03/10/2017] [Accepted: 04/05/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT Little is known about psychiatric illness and utilization of end-of-life care. OBJECTIVES We hypothesized that preexisting psychiatric illness would increase hospital utilization at end of life among patients with chronic medical illness due to increased severity of illness and care fragmentation. METHODS We reviewed electronic health records to identify decedents with one or more of eight chronic medical conditions based on International Classification of Diseases-9 codes. We used International Classification of Diseases-9 codes and prescription information to identify preexisting psychiatric illness. Regression models compared hospital utilization among patients with and without psychiatric illness. Path analyses examined the effect of severity of illness and care fragmentation. RESULTS Eleven percent of 16,214 patients with medical illness had preexisting psychiatric illness, which was associated with increased risk of death in nursing homes (P = 0.002) and decreased risk of death in hospitals (P < 0.001). In the last 30 days of life, psychiatric illness was associated with reduced inpatient and intensive care unit utilization but increased emergency department utilization. Path analyses confirmed an association between psychiatric illness and increased hospital utilization mediated by severity of illness and care fragmentation, but a stronger direct effect of psychiatric illness decreasing hospitalizations. CONCLUSION Our findings differ from the increased hospital utilization for patients with psychiatric illness in circumstances other than end-of-life care. Path analyses confirmed hypothesized associations between psychiatric illness and increased utilization mediated by severity of illness and care fragmentation but identified more powerful direct effects decreasing hospital use. Further investigation should examine whether this effect represents a disparity in access to preferred care.
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Affiliation(s)
- Kyle Lavin
- Department of Psychiatry and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dimitry S Davydow
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Ben Dunlap
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Kelson Okimoto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Medical Oncology, University of Washington, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Joan M Teno
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Gerontology and Geriatrics, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA.
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20
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Measuring Family Members' Satisfaction with End-of-Life Care in Long-Term Care: Adaptation of the CANHELP Lite Questionnaire. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4621592. [PMID: 28706945 PMCID: PMC5494554 DOI: 10.1155/2017/4621592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/28/2017] [Accepted: 04/20/2017] [Indexed: 11/17/2022]
Abstract
RATIONALE Improving end-of-life care (EOLC) in long-term care (LTC) homes requires quality measurement tools that assess families' satisfaction with care. This research adapted and pilot-tested an EOLC satisfaction measure (Canadian Health Care Evaluation Project (CANHELP) Lite Questionnaire) for use in LTC to measure families' perceptions of the EOLC experience and to be self-administered. METHODS AND RESULTS Phase 1. A literature review identified key domains of satisfaction with EOLC in LTC, and original survey items were assessed for inclusiveness and relevance. Items were modified, and one item was added. PHASE 2 The revised questionnaire was administered to 118 LTC family members and cognitive interviews were conducted. Further modifications were made including reformatting to be self-administered. PHASE 3 The new instrument was pilot-tested with 134 family members. Importance ratings indicated good content and face validity. Cronbach's alpha coefficients (range: .88-.94) indicated internal consistency. CONCLUSION This research adapted and pilot-tested the CANHELP for use in LTC. This paper introduces the new, valid, internally consistent, self-administered tool (CANHELP Lite Family Caregiver LTC) that can be used to measure families' perceptions of and satisfaction with EOLC. Future research should further validate the instrument and test its usefulness for quality improvement and care planning.
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21
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Cohen AB, Knobf MT, Fried TR. Do-Not-Hospitalize Orders in Nursing Homes: "Call the Family Instead of Calling the Ambulance". J Am Geriatr Soc 2017; 65:1573-1577. [PMID: 28369740 DOI: 10.1111/jgs.14879] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place. DESIGN Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014. SETTING Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010. PARTICIPANTS Nursing facility staff members (N = 31). MEASUREMENTS A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes. RESULTS DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred. CONCLUSION In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - M Tish Knobf
- Division of Acute Care/Health Systems, Yale School of Nursing, Yale University, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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22
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Palliative care during the final week of life of older people in nursing homes: A register-based study. Palliat Support Care 2017; 15:417-424. [DOI: 10.1017/s1478951516000948] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:Our aim was to explore the presence of symptoms, symptom relief, and other key aspects of palliative care during the final week of life among older people residing in nursing homes.Method:Our study employed data from the Swedish Palliative Care Register on all registered individuals aged 60 and older who had died in nursing homes during the years 2011 and 2012. Variables pertaining to monitoring and treatment of symptoms, end-of-life discussions, circumstances around the death, and the individual characteristics of deceased individuals were explored using descriptive statistics.Results:The most common underlying causes of death among the 49,172 deceased nursing home residents were circulatory diseases (42.2%) and dementia (22.7%). The most prevalent symptom was pain (58.7%), followed by rattles (42.4%), anxiety (33.0%), confusion (21.8%), shortness of breath (14.0%), and nausea (11.1%). Pain was the symptom with the highest degree of total relief (46.3%), whereas shortness of breath and confusion were totally relieved in 6.1 and 4.3% of all individuals, respectively. The use of valid instruments for symptom assessment was reported for pain in 12.3% and for other symptoms in 7.8% of subjects. The most prevalent individual prescriptions for injection PRN (pro re nata, according to circumstances) were for pain treatment (79.5%) and rattles (72.8%). End-of-life discussions were performed with 27.3% of all the deceased individuals and with 53.9% of their relatives. Of all individuals, 82.1% had someone present at death, and 15.8% died alone. Of all the nursing home resident deaths recorded, 45.3% died in their preferred place.Significance of results:There were large variations in degree of relief from different symptoms during the final week of life. Pain was the most prevalent symptom, and it was also the symptom with the highest proportion of total/partial relief. Other symptoms were less prevalent but also less well-relieved. Our results indicate a need for improvement of palliative care in nursing home settings, focusing on management of distressing symptoms and promotion of end-of-life discussions.
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Pan J(L, Chochinov H, Thompson G, McClement S. The TIME Questionnaire: A tool for eliciting personhood and enhancing dignity in nursing homes. Geriatr Nurs 2016; 37:273-7. [DOI: 10.1016/j.gerinurse.2016.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/21/2016] [Accepted: 03/28/2016] [Indexed: 10/21/2022]
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24
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Abrams RC. Sir James Reid and the Death of Queen Victoria: An Early Model for End-of-Life Care. THE GERONTOLOGIST 2015; 55:943-50. [DOI: 10.1093/geront/gnu016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 02/10/2014] [Indexed: 11/13/2022] Open
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25
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Unroe KT, Cagle JG, Miller SC. Response To Dr Raider's JAMDA Letter to the Editor. J Am Med Dir Assoc 2015; 16:435-6. [PMID: 25820132 DOI: 10.1016/j.jamda.2015.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Kathleen T Unroe
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indiana University School of Medicine, Indianapolis, IN
| | - John G Cagle
- University of Maryland-Baltimore School of Social Work, Baltimore, MD
| | - Susan C Miller
- Brown University School of Public Health, Providence, RI
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26
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Teno JM, Freedman VA, Kasper JD, Gozalo P, Mor V. Is Care for the Dying Improving in the United States? J Palliat Med 2015; 18:662-6. [PMID: 25922970 DOI: 10.1089/jpm.2015.0039] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Striking changes occurred in health care in the United States between 2000 and 2013, including growth of hospice and hospital-based palliative care teams, and changes in Medicare payment policies. OBJECTIVE The aim of this study was to compare informants' reports and ratings of the quality of end-of-life care for decedents between 2000 and 2011-2013. METHODS The study design comprised retrospective national surveys. Subjects were decedents age 65 years and older residing in the community from two time periods. Similar survey questions were asked at the two time periods. Bivariate and multivariate analyses were conducted, using appropriate survey weights to examine response differences between time periods, after adjusting for the decedent's age, race, pattern of functional decline, and the presence of a cancer diagnosis, as well as the respondent's relationship to the decedent. RESULTS A total of 1208 informants were interviewed; 622 in 2000 and 586 in 2011-2013. Respondents from deaths in 2011-2013 were more likely to state that their loved ones experienced an unmet need for pain management (25.2% versus 15.5% in 2000, adjusted odds ratio [AOR] 1.9, 95% confidence interval [CI] 1.1-3.3). More respondents reported that religion and spirituality were addressed in the later time period (72.4% not addressed compared with 58.3%, AOR 1.4, 95% CI 1.1-1.9). High rates of unmet need for palliation of dyspnea and anxiety/depression remained. The overall rating of quality did not improve but decreased (with 56.7% stating care was excellent in 2000 and 47.0% in the later survey, AOR 0.70, 95% CI 0.52-0.95). CONCLUSIONS Substantial unmet needs in end-of-life care remain. Continued efforts are needed to improve the quality of end-of-life care.
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Affiliation(s)
- Joan M Teno
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
| | - Vicki A Freedman
- 2 Institute for Social Research, University of Michigan , Ann Arbor, Michigan
| | - Judith D Kasper
- 3 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Pedro Gozalo
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
| | - Vincent Mor
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
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27
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Physicians in nursing homes: effectiveness of physician accountability and communication. J Am Med Dir Assoc 2015; 16:755-61. [PMID: 25858283 DOI: 10.1016/j.jamda.2015.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The objective of this study was to develop a measure of the perceptions of nursing home (NH) directors of nursing (DONs) on the adequacy of physician care and to examine its variation as well as its construct validity. DESIGN A nationwide cross-sectional study with primary data collection. SETTING A total of 2043 NHs surveyed between August 2009 and April 2011. PARTICIPANTS DONs and NH administrators responded to questions pertaining to their perceptions of the care provided by physicians in their NH. MEASUREMENTS Ten items were used to create 3 domains: medical staff attentiveness, physician communication, and staff concerns about physician practice. These were combined into an overall summary score measure called "Effectiveness of Physician Accountability and Communication" (EPAC). EPAC construct validity was ascertained from other DON questions and from a complementary survey of NH administrators. RESULTS The established EPAC score is the first measure to capture specific components of the adequacy of physician care in NHs. EPAC exhibited good construct validity: more effective practices were correlated with greater physician involvement in discussions of do-not-resuscitate orders, the frequency with which the medical director checked on the medical care delivered by the attending physician, the tightness of the NH's control of its physician resources, and the DON's perception of whether or not avoidable hospitalizations and emergency room visits could be reduced with greater physician attention to resident needs. CONCLUSION As increased attention is given to the quality of care provided to vulnerable elders, effective measures of processes of care are essential. The EPAC measure provides an important new metric that can be used in these efforts. The goal is that future studies could use EPAC and its individual domains to shed light on the manner through which physician presence is related to resident outcomes in the NH setting.
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Hwang D, Teno JM, Clark M, Shield R, Williams C, Casarett D, Spence C. Family perceptions of quality of hospice care in the nursing home. J Pain Symptom Manage 2014; 48:1100-7. [PMID: 24819082 PMCID: PMC7053228 DOI: 10.1016/j.jpainsymman.2014.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/04/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT Nursing homes (NHs) are increasingly the site of hospice care. High quality of care is dependent on successful NH-hospice collaboration. OBJECTIVES To examine bereaved family members' perceptions of NH-hospice collaborations in terms of what they believe went well or could have been improved. METHODS Focus groups were conducted with bereaved family members from five diverse geographic regions, and included participants from inner city and rural settings, with oversampling of African Americans. RESULTS A total of 28 participants (14.8% African American, mean age 61.4 years) identified three major aspects of collaboration as important to care delivery. First, most (67.9%) voiced concerns with knowing who (NH or hospice) is responsible for which aspects of patient care. Second, nearly half (42.9%) stated concern about information coordination between the NH and hospice. Finally, 67.9% of the participants mentioned the need for hospice to advocate for high-quality care rather than their having to directly do so on behalf of their family members. CONCLUSION The important concerns raised by bereaved family members about NH-hospice collaboration have been incorporated into the revised Family Evaluation of Hospice Care, a post-death survey used to evaluate quality of hospice care.
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Affiliation(s)
| | - Joan M Teno
- Brown University Providence, Rhode Island, USA.
| | | | | | | | - David Casarett
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carol Spence
- National Hospice and Palliative Care Organization, Alexandria, Virginia, USA
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Gage LA, Washington K, Oliver DP, Kruse R, Lewis A, Demiris G. Family Members' Experience With Hospice in Nursing Homes. Am J Hosp Palliat Care 2014; 33:354-62. [PMID: 25422516 DOI: 10.1177/1049909114560213] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Research has documented numerous benefits and challenges associated with receipt of hospice care in nursing homes; however, study of this partnership from the perspective of residents' family members has been limited. The purpose of this qualitative investigation was to explore family members' experience with hospice services received in the nursing home setting. Researchers conducted a secondary data analysis of 175 family member interviews using a thematic analytic approach. Findings highlighted the critical role of communication in supporting residents and their family members. Care coordination, support and oversight, and role confusion also impacted family members' experience of hospice care in the nursing home. Efforts directed at enhancing communication and more clearly articulating the roles of members of the health care team are indicated.
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Affiliation(s)
- L Ashley Gage
- Department of Social Work, University of Nebraska-Kearney, Kearney, NE, USA
| | - Karla Washington
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Debra Parker Oliver
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Robin Kruse
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Alexandra Lewis
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - George Demiris
- Biobehavioral Nursing and Health Systems, School of Nursing & Biomedical and Health Informatics, School of Medicine, University of Washington, Seattle, WA, USA
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Fosse A, Schaufel MA, Ruths S, Malterud K. End-of-life expectations and experiences among nursing home patients and their relatives--a synthesis of qualitative studies. PATIENT EDUCATION AND COUNSELING 2014; 97:3-9. [PMID: 24976628 DOI: 10.1016/j.pec.2014.05.025] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 05/20/2014] [Accepted: 05/30/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Synthesize research about patients' and relatives' expectations and experiences on how doctors can improve end-of-life care in nursing homes. METHODS We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography. RESULTS Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients' ability to consent, and patients' preferences were not always recognized. CONCLUSION Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief. PRACTICE IMPLICATIONS High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | | | - Sabine Ruths
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Research Unit for General Practice, Copenhagen, Denmark
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Teo WSK, Raj AG, Tan WS, Ng CWL, Heng BH, Leong IYO. Economic impact analysis of an end-of-life programme for nursing home residents. Palliat Med 2014; 28:430-7. [PMID: 24651709 DOI: 10.1177/0269216314526270] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to limited end-of-life discussions and the absence of palliative care, hospitalisations are frequent at the end of life among nursing home residents in Singapore, resulting in high health-care costs. AIM Our objective was to evaluate the economic impact of Project Care at the End-of-Life for Residents in homes for the Elderly (CARE) programme on nursing home residents compared to usual end-of-life care. DESIGN AND SETTINGS/PARTICIPANTS: Project CARE was introduced in seven nursing homes to provide advance care planning and palliative care for residents identified to be at risk of dying within 1 year. The cases consisted of nursing home residents enrolled in the Project CARE programme for at least 3 months. A historical group of nursing home residents not in any end-of-life care programme was chosen as the matched controls. Cost differences between the two groups were analysed over the last 3 months and final month of life. RESULTS The final sample comprised 48 Project CARE cases and 197 controls. Compared to the controls, the cases were older with more comorbidities and higher nursing needs. After risk adjustment, Project CARE cases demonstrated per-resident cost savings of SGD$7129 (confidence interval: SGD$4544-SGD$9714) over the last 3 months of life and SGD$3703 (confidence interval: SGD$1848-SGD$5557) over the last month of life (US$1 = SGD$1.3). CONCLUSION This study demonstrated substantial savings associated with an end-of-life programme. With a significant proportion of the population in Singapore requiring nursing home care in the near future, these results could assist policymakers and health-care providers in decision-making on allocation of health-care resources.
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Affiliation(s)
- W-S Kelvin Teo
- 1Health Services & Outcomes Research, National Healthcare Group, Singapore
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Shield R, Rosenthal M, Wetle T, Tyler D, Clark M, Intrator O. Medical staff involvement in nursing homes: development of a conceptual model and research agenda. J Appl Gerontol 2014; 33:75-96. [PMID: 24652944 PMCID: PMC3962951 DOI: 10.1177/0733464812463432] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Medical staff (physicians, nurse practitioners, physicians' assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian "structure-process-outcomes" framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies.
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Affiliation(s)
- Renée Shield
- Health Services, Policy & Practice, Brown University, Providence, RI, USA
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Lopez RP, Mazor KM, Mitchell SL, Givens JL. What is family-centered care for nursing home residents with advanced dementia? Am J Alzheimers Dis Other Demen 2013; 28:763-8. [PMID: 24085250 PMCID: PMC4120188 DOI: 10.1177/1533317513504613] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To understand family members' perspectives on person- and family-centered end-of-life care provided to nursing home (NH) residents with advanced dementia, we conducted a qualitative follow-up interview with 16 respondents who had participated in an earlier prospective study, Choices, Attitudes, and Strategies for Care of Advance Dementia at End of Life (CASCADE). Family members of NH residents (N = 16) with advanced dementia participated in semistructured qualitative interviews that inquired about overall NH experience, communication, surrogate decision making, emotional reaction, and recommendations for improvement. Analysis identified 5 areas considered important by family members: (1) providing basic care; (2) ensuring safety and security; (3) creating a sense of belonging and attachment; (4) fostering self-esteem and self-efficacy; and (5) coming to terms with the experience. These themes can provide a framework for creating and testing strategies to meet the goal of person- and family-centered care.
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Affiliation(s)
- Ruth Palan Lopez
- MGH Institute of Health Professions, School of Nursing, Boston, MA, USA
| | - Kathleen M. Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - Susan L. Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jane L. Givens
- Hebrew SeniorLife, Institute for Aging Research, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Bakitas M, Lyons KD, Hegel MT, Ahles T. Oncologists' perspectives on concurrent palliative care in a National Cancer Institute-designated comprehensive cancer center. Palliat Support Care 2013; 11:415-23. [PMID: 23040412 PMCID: PMC3797174 DOI: 10.1017/s1478951512000673] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of this study was to understand oncology clinicians' perspectives about the care of advanced cancer patients following the completion of the ENABLE II (Educate, Nurture, Advise, Before Life Ends) randomized clinical trial (RCT) of a concurrent oncology palliative care model. METHOD This was a qualitative interview study of 35 oncology clinicians about their approach to patients with advanced cancer and the effect of the ENABLE II RCT. RESULTS Oncologists believed that integrating palliative care at the time of an advanced cancer diagnosis enhanced patient care and complemented their practice. Self-assessment of their practice with advanced cancer patients comprised four themes: (1) treating the whole patient, (2) focusing on quality versus quantity of life, (3) “some patients just want to fight,” and (4) helping with transitions; timing is everything. Five themes comprised oncologists' views on the complementary role of palliative care: (1) “refer early and often,” (2) referral challenges: “Palliative” equals “hospice”; “Heme patients are different,” (3) palliative care as consultants or co-managers, (4) palliative care “shares the load,” and (5) ENABLE II facilitated palliative care integration. SIGNIFICANCE OF RESULTS Oncologists described the RCT as holistic and complementary, and as a significant factor in adopting concurrent care as a standard of care.
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Affiliation(s)
- Marie Bakitas
- Department of Anesthesiology, Section of Palliative Medicine, Geisel School of Medicine, Hanover, NH
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | | | - Mark T. Hegel
- Department of Psychiatry, Geisel School of Medicine, Hanover, NH
| | - Tim Ahles
- Department of Psychiatry, Memorial Sloan-Kettering Cancer Center, NY
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Kihlgren A, Wimo A, Mamhidir AG. Older patients referred by community nurses to emergency departments - a descriptive cross-sectional follow-up study in a Swedish context. Scand J Caring Sci 2013; 28:97-103. [DOI: 10.1111/scs.12044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 03/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Annica Kihlgren
- School of Health and Medical Sciences; Örebro University; Örebro Sweden
| | - Anders Wimo
- Department of Neurobiology, Caring Sciences and Society; KI-Alzheimer Disease Research Center (KI-ADRC); Karolinska Institute; Stockholm Sweden
| | - Anna-Greta Mamhidir
- Department of Health and Caring Sciences; Faculty of Health and Occupational Studies; University of Gävle; Gävle Sweden
- Department of Public Health and Caring Sciences; Uppsala University; Uppsala Sweden
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Gjerberg E, Hem MH, Førde R, Pedersen R. How to avoid and prevent coercion in nursing homes. Nurs Ethics 2013; 20:632-44. [DOI: 10.1177/0969733012473012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.
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Sources of stress for family members of nursing home residents with advanced dementia. Alzheimer Dis Assoc Disord 2013; 26:254-9. [PMID: 22037596 DOI: 10.1097/wad.0b013e31823899e4] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The sources of stress for families of nursing home (NH) residents with advanced dementia have not been well described. Semistructured interviews were conducted with 16 family members previously enrolled in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective cohort of 323 NH residents with advanced dementia and their family members. Questions were asked pertaining to the experience of having a family member in the NH, communication with health-care professionals, surrogate decision making, emotional distress, and recommendations for improvement in care. Transcripts were analyzed using the constant comparative method. The majority of the participants were women (63%), children of the resident (94%), and white (94%). The average age was 62 years. Four themes emerged: (1) inadequate resident personal care, resulting in family member vigilance and participation in care; (2) stress at the time of NH admission; (3) lack of communication with NH physicians; and (4) challenges of surrogate decision making, including the need for education to support advance care planning and end-of-life decisions. Our results support the provision of emotional support to families upon resident admission, education regarding prognosis to guide decision making, improved resident care, and greater communication with health care professionals.
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Ersek M, Sefcik JS, Lin FC, Lee TJ, Gilliam R, Hanson LC. Provider staffing effect on a decision aid intervention. Clin Nurs Res 2013; 23:36-53. [PMID: 23291316 DOI: 10.1177/1054773812470840] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined the association between Nurse Practitioner (NP) and Physician Assistant (PA) staffing in nursing homes and the effect of a decision aid regarding feeding options in dementia on the frequency of surrogate-provider discussions and on surrogates' decisional conflict. We compared these outcomes for facilities that had no NPs/PAs, part-time-only NP/PA staffing, and full-time NP/PA staffing. The sample included 256 surrogate decision makers from 24 nursing homes. The decision aid was associated with significant increases in discussion rates in facilities with part-time or no NP/PA staffing (26% vs. 51%, p < .001, and 13% vs. 41%, p < .001, respectively) and decreases in decisional conflict scores (-0.08 vs. -0.047, p = .008, and -0.30 vs. -0.68, p = .014, respectively). Sites with full-time NP/PA staffing had high baseline rates of discussions (41%). These findings suggest that the decision aid and full-time NP/PA staffing can enhance surrogate decision making in nursing homes.
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Affiliation(s)
- Mary Ersek
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
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Abstract
RÉSUMÉNous avons examiné les caractéristiques contextuelles qui façonnent les soins de fin de vie (SFV) dans les établissements de soins pour bénéficiaires, en s’appuyant sur les perspectives de 11 aidants résidents (AR) dans un centre urbain canadien de l’Ouest. ARs décrivent les soins de fin de vie comme “offrant un confort,” y compris le bien-être physique et émotionnel. Les inquiétudes au sujet des défis posés par le temps et la charge de travail ont dominé les comptes et ont généré la culpabilité, la tristesse et de la frustration. ARs ont essayé de “trouver le temps” en le prenant d’eux-mêmes ou les autres résidents, et en s’appuyant sur l’engagement des collègues et sur les familles. Les résultats soulignent l’importance du rôle d’AR (en particulier en offrant un confort émotionnel), mais faire appel à l’attention à l’interprétation de ce qui est impliqué dans ce travail, et à la définition du portée de la pratique et de la formation. Les résultats également réitère l’importance, entre aidants résidents canadiens, des charges de travail adéquates pour faciliter les soins de fin de vie de qualité, et soulève des préoccupations au sujet des contraintes et comment elles forment la pratique de soins de fin de vie et les significations qui infusent une telle pratique.
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Thompson GN, McClement SE, Menec VH, Chochinov HM. Understanding bereaved family members' dissatisfaction with end-of-life care in nursing homes. J Gerontol Nurs 2012; 38:49-60. [PMID: 22998093 DOI: 10.3928/00989134-20120906-94] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 04/03/2012] [Indexed: 12/31/2022]
Abstract
With increasing numbers of older adults identifying a nursing home (NH) as their final place of care, it is important to assess the quality of dying in this setting and understand factors that impact family members' dissatisfaction with end-of-life care. A retrospective bereaved family member survey (N = 208) was conducted in 21 NHs located in urban areas of central Canada. Bereaved family members who were dissatisfied with care identified significantly more concerns in all domains assessed and were more likely to have problems with: (a) receiving confusing information from nursing staff about the resident's care, including medical treatments; (b) receiving inadequate information from nursing staff; and (c) feeling that end-of-life care was different than they had expected. Since the quality of communication between nurses, residents, and family members is the main factor that determines families' dissatisfaction with care, strategies and interventions aimed at reducing unmet information needs will be vital to improving end-of-life care in NHs.
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Williams SW, Zimmerman S, Williams CS. Family caregiver involvement for long-term care residents at the end of life. J Gerontol B Psychol Sci Soc Sci 2012; 67:595-604. [PMID: 22929400 PMCID: PMC3536551 DOI: 10.1093/geronb/gbs065] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 06/20/2012] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To examine family caregiver involvement for long-term care (LTC) residents during the last month of life. Researchers examined direct (personal care and meals) and indirect (management and monitoring) types of caregiver involvement and the relationship between the type of involvement and predisposing, enabling, and need characteristics. Researchers also examined whether the frequency of involvement changed during the end-of-life (EOL) period. METHOD Researchers used an expanded version of Andersen's Behavioral Model to conceptualize predictors of family involvement for 438 residents in 125 residential care/assisted living and nursing home settings. Bivariate and multivariate analyses examined relationships among variables. RESULTS More than one-half of family caregivers monitored, managed care and assisted with meals, and 40% assisted with personal care tasks. The enabling characteristic of days visited and the need characteristic of caregiver role strain were related to each of the 4 types of involvement. However, the other correlates were distinct to the type of involvement. DISCUSSION Families are involved in EOL care in LTC settings. Higher role strain is related to more involvement in each of the 4 types of involvement, suggesting that whether involvement is by desire, perceived need, or both, there is cause to more critically examine the family caregiver's desired role and need for support.
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Affiliation(s)
- Sharon W Williams
- Department of Allied Health Sciences, Division of Speech and Hearing Sciences, University of North Carolina at Chapel Hill, Bondurant Hall, CB 7190, Chapel Hill, NC 27599, USA.
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Direct care staff and parents'/legal guardians' perspectives on end-of-life care in a long-term care facility for medically fragile and intellectually disabled pediatric and young adult residents. Palliat Support Care 2012; 11:307-14. [DOI: 10.1017/s1478951512000326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Children and young adults with severe disabilities and their families are faced with enormous challenges throughout the lifespan, including admitting the child to a long-term care facility (LTCF) and making end-of-life (EOL) care decisions. While children are residents of these specialized LTCF, the majority of their daily care, even up until death, is provided by nursing aides or habilitation aides (HAs) with limited training and educational backgrounds compared with other licensed healthcare providers. The purpose of this study was to determine the impact of a resident's EOL experience on the primary HAs and parents/guardians.Method:Thirty-five resident deaths occurred at Hattie Larlham Center for Children with Disabilities (HLCCD) between January 1, 2006 and February 28, 2009. The HAs and parents/legal guardians were identified for each death and invited to complete three surveys per resident (FAMCARE, Impact of Events Scale (IES)-revised, and Perspective on End-of-Life Care) to assess their experience. There were 112 surveys mailed to 62 HAs and 47 surveys mailed to 47 parents.Results:Forty-two surveys were returned from 18/62 HAs (response rate 29%) and 11/47 parents/legal guardians completed the surveys (response rate 23%). The FAMCARE survey found that parents were more satisfied with the EOL care than were the HAs. The IES-revised found no difference in traumatic responses from either group. Comments from the Perspective on End-of-Life Care survey were analyzed qualitatively for common themes including pain control, respect, decision making, environmental needs, resources, and support.Significance of results:Because of a low response rate, it was difficult to draw significant conclusions; however, several interesting trends were noted regarding the number of deaths HAs experienced, satisfaction with care, and distress. The special needs of this population and their caregivers can provide crucial insights into interventions (e.g. chaplaincy support, debriefings, anticipatory counseling, environmental changes) that might be of benefit for any caregiver or parent of a child with a long-term, chronic condition, particularly involving developmental disability.
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Schmidt-RioValle J, Montoya-Juarez R, Campos-Calderon CP, Garcia-Caro MP, Prados-Peña D, Cruz-Quintana F. Efectos de un programa de formacion en cuidados paliativos sobre el afrontamiento de la muerte. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.medipa.2010.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Nursing home medical staff organization and 30-day rehospitalizations. J Am Med Dir Assoc 2012; 13:552-7. [PMID: 22682694 DOI: 10.1016/j.jamda.2012.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/19/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To examine the relationship between features of nursing home (NH) medical staff organization and residents' 30-day rehospitalizations. DESIGN Cross-sectional study combining primary data collected from a survey of medical directors, NH resident assessment data (minimum data set), Medicare claims, and the Online Survey Certification and Reporting (OSCAR) database. SETTING A total of 202 freestanding US nursing homes. PARTICIPANTS Medicare fee-for-service beneficiaries who were hospitalized and subsequently admitted to a study nursing home. MEASUREMENTS Medical staff organization dimensions derived from the survey, NH residents' characteristics derived from minimum data set data, hospitalizations obtained from Part A Medicare claims, and NH characteristics from the OSCAR database and from www.ltcfocus.org. Study outcome defined within a 30-day window following an index hospitalization: rehospitalized, otherwise died, otherwise survived and not rehospitalized. RESULTS Thirty-day rehospitalizations occurred for 3788 (20.3%) of the 18,680 initial hospitalizations. Death was observed for 884 (4.7%) of residents who were not rehospitalized. Adjusted by hospitalization, resident, and NH characteristics, nursing homes having a more formal appointment process for physicians were less likely to have 30-day rehospitalization (b = -0.43, SE = 0.17), whereas NHs in which a higher proportion of residents were cared for by a single physician were more likely to have rehospitalizations (b = 0.18, SE = 0.08). CONCLUSION This is the first study to show a direct relationship between features of NH medical staff organization and resident-level process of care. The relationship of a more strict appointment process and rehospitalizations might be a consequence of more formalized and dedicated medical practice with a sense of ownership and accountability. A higher volume of patients per physician does not appear to improve quality of care.
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Liu LM, Guarino AJ, Lopez RP. Family Satisfaction With Care Provided by Nurse Practitioners to Nursing Home Residents With Dementia at the End of Life. Clin Nurs Res 2011; 21:350-67. [DOI: 10.1177/1054773811431883] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to examine family satisfaction with care provided by nurse practitioners (NP) to nursing home (NH) residents with dementia. A survey was mailed to 239 family members of nursing home residents who died with dementia. One open-ended question was added to provide comment about the care provided by the NP. A total of 131 surveys were returned (response rate 55%). The study revealed that 98% of family members agreed that they were satisfied with the end-of-life care provided by the NP. Survey responses were used to analyze the associations of communication, comfort, and satisfaction with NPs to total satisfaction with end-of-life care. Pearson’s correlations demonstrated that overall satisfaction was significantly associated with NP–family communication, resident comfort, and satisfaction with NP care. Findings suggested that NPs using a model of care that emphasizes advance care planning, communication, and comfort results in high satisfaction of family members.
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Affiliation(s)
| | - A. J. Guarino
- MGH Institute of Health Professions, Boston, MA, USA
| | - Ruth Palan Lopez
- MGH Institute of Health Professions School of Nursing, Boston, MA, USA
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Huskamp HA, Kaufmann C, Stevenson DG. The Intersection of Long-Term Care and End-of-Life Care. Med Care Res Rev 2011; 69:3-44. [DOI: 10.1177/1077558711418518] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.
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Dreyer A, Førde R, Nortvedt P. Ethical decision-making in nursing homes: Influence of organizational factors. Nurs Ethics 2011; 18:514-25. [DOI: 10.1177/0969733011403553] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this article we report findings from a qualitative study that explored how doctors and nurses in nursing homes describe professional collaboration around dying patients. The study also examined the consequences this can have for the life-prolonging treatment of patients and the care of them and their relatives. Nine doctors and 10 nurses from 10 Norwegian nursing homes were interviewed about their experience of decision-making processes on life-prolonging treatment and care. The findings reveal that the frameworks for the professional collaboration and organization of physicians and nurses prevent patient treatment and care complying with ethical considerations and the law. These conditions have a challenging impact on the care of dying patients and their relatives.
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Shanley C, Whitmore E, Conforti D, Masso J, Jayasinghe S, Griffiths R. Decisions about transferring nursing home residents to hospital: highlighting the roles of advance care planning and support from local hospital and community health services. J Clin Nurs 2011; 20:2897-906. [PMID: 21539626 DOI: 10.1111/j.1365-2702.2010.03635.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Christopher Shanley
- Aged Care Research Unit, Liverpool Hospital, University of New South Wales, Sydney, Australia.
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Goddard C, Stewart F, Thompson G, Hall S. Providing end-of-life care in care homes for older people: a qualitative study of the views of care home staff and community nurses. J Appl Gerontol 2011; 32:76-95. [PMID: 25473926 DOI: 10.1177/0733464811405047] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The study aimed to explore the views of care home staff (CHS) and community nurses (CNs) on providing end-of-life care (EOLC) in care homes. Participants were randomly selected and qualitative interviews conducted with 80 CHS and 10 CNs. Themes emerging from the data included the following: The meaning of EOLC; starting EOLC; dying in the care home; stress of providing EOLC; improving EOLC; and the role of the CN. CHS felt that planning for the end of life was important before residents reached the dying phase, which some found difficult to determine. Although CHS wished to avoid residents being transferred to hospital to die, they acknowledged that improvements in their skills and the resources available to them were needed to manage EOLC effectively. CNs were critical of the EOLC provided in some care homes, reporting tensions over their relationship with CHS. As the number of older people who die in care homes increases, there is a need to overcome these barriers to provide good EOLC.
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Seymour JE, Kumar A, Froggatt K. Do nursing homes for older people have the support they need to provide end-of-life care? A mixed methods enquiry in England. Palliat Med 2011; 25:125-38. [PMID: 21282349 PMCID: PMC3057627 DOI: 10.1177/0269216310387964] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nursing homes are a common site of death, but older residents receive variable quality of end-of-life care. We used a mixed methods design to identify external influences on the quality of end-of-life care in nursing homes. Two qualitative case studies were conducted and a postal survey of 180 nursing homes surrounding the case study sites. In the case studies, qualitative interviews were held with seven members of nursing home staff and 10 external staff. Problems in accessing support for end-of-life care reported in the survey included variable support by general practitioners (GPs), reluctance among GPs to prescribe appropriate medication, lack of support from other agencies, lack of out of hours support, cost of syringe drivers and lack of access to training. Most care homes were implementing a care pathway. Those that were not rated their end-of-life care as in need of improvement or as average. The case studies suggest that critical factors in improving end-of-life care in nursing homes include developing clinical leadership, developing relationships with GPs, the support of 'key' external advocates and leverage of additional resources by adoption of care pathway tools.
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Affiliation(s)
- Jane E Seymour
- The Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, UK.
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