The end-of-life experience in long-term care: five themes identified from focus groups with residents, family members, and staff

Nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents- a qualitative study

BACKGROUND

Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto's theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses' perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

METHODS

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

RESULTS

The content analysis generated five categories that were labelled similar to Tronto's five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses' autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto's theory contributes to greater reflectiveness around what may constitute 'good' end-of-life care.

CONCLUSIONS

Tronto's care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto's care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what 'good' end-of-life care should be.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia.

RESEARCH DESIGN AND METHODS

One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening).

RESULTS

The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect.

DISCUSSION AND IMPLICATIONS

The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.

"You gotta have your cry": Administrator and direct care worker experiences of death in assisted living

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and 38 direct care workers (DCWs) in 7 diverse settings. As assisted living administrators and DCWs experienced resident death, they engaged in a dynamic and individualized process of "managing the normalization of death," which refers to the balance of self-identity and workplace identity. The process of reconciling these opposing contexts in AL involved several individual- and community-level conditions. Administrators and DCWs would benefit from additional resources and training around death. Increasing collaboration with hospice and clarifying policies about death communication would better prepare the workforce to acknowledge the end of life in assisted living.

Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol

BACKGROUND

Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia.

METHODS/DESIGN

This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners.

DISCUSSION

This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.

Development of an intervention (PICASO) to optimise the palliative care capacity of social workers in Flanders: a study protocol based on phase I of the Medical Research Council framework

INTRODUCTION

An important challenge for future palliative care delivery is the growing number of people with palliative care needs compared with the limited qualified professional workforce. Existing but underused professional potential can further be optimised. This is certainly the case for social work, a profession that fits well in multidisciplinary palliative care practice but whose capacities remain underused. This study aims to optimise the palliative care capacity of social workers in Flanders (Belgium) by the development of a Palliative Care Program for Social Work (PICASO).

METHODS AND ANALYSIS

This protocol paper covers the steps of the development of PICASO, which are based on phase I of the Medical Research Council framework. However, additional steps were added to the original framework to include more opportunities for stakeholder involvement. The development of PICASO follows an iterative approach. First, we will identify existing evidence by reviewing the international literature and describe the problem by conducting quantitative and qualitative research among Flemish social workers. Second, we will further examine practice and identify an appropriate intervention theory by means of expert panels. Third, the process and outcomes will be depicted in a logic model.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by the KU Leuven Social and Societal Ethics Committee (SMEC) on 14 April 2021 (reference number: G-2020-2247-R2(MIN)). Findings will be disseminated through professional networks, conference presentations and publications in scientific journals.

A Scoping Review on the Experience of Participating in Dignity Therapy for Adults at the End of Life

Background: As the proportion of aging population is increasing, so is the need for palliative care services. The end of life is marked by suffering and currently it is not well addressed in palliative care. Dignity therapy (DT) is one of the most popular therapies aimed at reducing suffering at the life and yet the quantitative evidence supporting its effectiveness is mixed. Also, no study has looked extensively at the qualitative literature. Objective: To describe the experience of participating in DT for adults in end of life. Design: A scoping review was conducted on the experience of DT among adults at their end of life. We searched electronic databases between 2002 and 2020. Two reviewers independently screened, extracted, and coded the data. They were analyzed using a thematic framework approach. Results: Twelve articles were included in the final analysis and were published between 2010 and 2019. The articles originated from the United States (3), Canada (3), Poland (2), Australia (2), the United Kingdom (2), Italy (1), and Germany (1). Two main categories of themes emerged from our analysis: themes mentioned during the DT intervention and themes following the DT intervention. The primary themes found during the DT intervention are discussions relating to the end of life, reflection on life, and creating a life narrative. The themes found following the DT intervention are that it opened a reflection on the past, that this was a helpful intervention, and that it was difficult, but important. Conclusions: Few qualitative studies assessed the experience of participating in DT following the intervention. This gap in the literature could explain the difficulties we currently have in understanding the effects of DT. Future studies should aim to assess how the effects of DT are perceived by patients after the intervention.

"You Lose Some Good Friends": Death and Grief in Assisted Living

The purpose of this study was to investigate responses to death at multiple levels within the assisted living (AL) system and to characterize the psychosocial impact of death on surviving residents. This study used secondary thematic analysis of multiple data sources collected as part of a larger quantitative-focused study with 21 ALs. Data sources included: (a) community documents, e.g., newsletters; (b) descriptive and reflective observational field notes; and (c) memos and key statements from interviews with residents (n = 18). Three themes emerged from the data: administrative memorialization practices, resident perceptions of staff communication related to death, and resident psychosocial responses to death. Surviving residents reported using both adaptive and avoidant strategies to cope with psychological responses to death; noting that grief responses extended to the loss of the deceased resident's family, friends, and pets. Residents also perceived staff-resident communication and community memorialization practices as incongruent with a "family-like" social climate. Findings highlight the potential utility of a multi-level approach to improving psychosocial aspects of end-of-life care and grief management by targeting AL administration, workforce, and individuals. Social workers are well-positioned to lead these types of psychosocial interventions but must contend with staffing barriers limiting clinical roles in AL.

The relationship between caregivers' perceptions of end-of-life care in long-term care and a good resident death

OBJECTIVE

Quality end-of-life (EOL) care is critical for dying residents and their family/friend caregivers. While best practices to support resident comfort at EOL in long-term care (LTC) homes are emerging, research rarely explores if and how the type of care received at EOL may contribute to caregivers' perceptions of a good death. To address this gap, this study explored how care practices at EOL contributed to caregivers' perceptions of a good resident death.

METHOD

This study used a retrospective cross-sectional survey design. Seventy-eight participants whose relative or friend died in one of five LTC homes in Canada completed self-administered questionnaires on their perceptions of EOL care and perceptions of a good resident death.

RESULTS

Overall, caregivers reported positive experiences with EOL care and perceived residents to have died a good death. However, communication regarding what to expect in the final days of life and attention to spiritual issues were often missing components of care. Further, when explored alongside direct resident care, family support, and rooming conditions, staff communication was the only aspect of EOL care significantly associated with caregivers' perceptions of a good resident death.

SIGNIFICANCE OF RESULTS

The findings of this study suggest that the critical role staff in LTC play in supporting caregivers' perceptions of a good resident death. By keeping caregivers informed about expectations at the very end of life, staff can enhance caregivers' perceptions of a good resident death. Further, by addressing spiritual issues staff may improve caregivers' perceptions that residents were at peace when they died.

Take it to the resident: A model for engaging long-term stay residents in advance care planning

Advance care planning involves a meaningful conversation about residents' end of life goals with the health-care team and documenting these wishes in advance directives; however, these conversations are not taking place early enough or with strategies that allow nursing home residents' preferences to be meaningfully integrated into care plans. This article outlines a new model that nursing home social workers can use to initiate advance care planning discussions called Take it to the Resident. This model was tested with 11 long-term stay nursing home residents. Data were collected through structured memos and field notes. Summative content analysis was utilized to analyze the data. Take it to the Resident facilitated a discussion about advance care planning and allowed residents to consider their wishes before engaging family members. Although discussions took place, some residents were hesitant to document their wishes formally through advance directives. The results of this study support the utility of continued testing of this model. Having empirically supported tools for nursing home social workers is critical to increasing advance care planning conversations and empowering residents to document their wishes.

Patients' Dying Process From the Point of View of Family and Hospice Team: A Qualitative Exploration of Family Member and Hospice Team Experiences With Hospice in Korea

The aims of this study is to analyze the experiences of family members and hospice teams regarding hospice care in Korea where culture and institution for well-dying is in the early stage. The study was conducted through in-depth interviews based on the grounded theory method. The participants were 12 individuals, 5 family members and 7 individuals from the hospice team. 133 concepts, 34 subcategories, and 11 categories were derived. The core phenomenon was "maintaining balance by becoming a ballast in the journey toward death". From the analysis of paradigm model, this phenomenon was caused to the medical-centered hospice service, the negative social and cultural context of death. It was strategically responded to the scope and contents of the interventions by the hospice team. Systematic, policy, and implementation plans that could improve the quality of hospice care were discussed.

Organizational Characteristics of Assisted Living Communities With Policies Supportive of Admitting and Retaining Residents in Need of End-of-Life Care

BACKGROUND

There has been a rapid increase in the number of residential care/assisted living communities (RC/AL) that allow residents to die in place. The objective of this study was to examine the organizational characteristics of RC/AL communities that are associated with facility-level policies supportive of admitting and retaining residents in need of end-of-life (EOL) care.

METHODS

We used cross-sectional data from the 2010 National Survey of Residential Care Facilities. Organizational characteristics included structural factors, staffing levels, and other relevant facility-level policies. We examined descriptive statistics, binomial and multivariable multinomial regression models to determine the likelihood of 1) admitting and retaining, or 2) only retaining, as compared to 3) neither admitting nor retaining AL residents in need of EOL care.

RESULTS

A majority of residential care facilities 73.7% (n = 22,642) reported admitting and retaining residents at EOL. Yet, levels of skilled nursing care were generally low with 60.9% of these RC/AL communities reporting that registered nurses were not available, including hospice staff. In multivariable, multinomial regression models, organizational characteristics such as skilled nursing, hands-on contact hours from personal care aides, and policies allowing exemptions to self-evacuation rules were associated with increased likelihood of RC/AL communities admitting/retaining residents in need of EOL care.

CONCLUSION

Despite overall low levels of skilled nursing care, a nationally representative survey revealed that a majority of RC/AL communities admit and retain residents in need of EOL care. Staffing and exemptions from self-evacuation policies appear to be central characteristics associated with the provision of these services in RC/AL communities.

Thematic Analysis of Interprofessional Provider Perceptions of Pediatric Death

PURPOSE

Though provider and patient perceptions of death are characterized in the adult population literature, there is limited information related to providers' perceptions in pediatric and neonatal patients. The purpose of this study was to better understand how interprofessional care team members perceive and experience neonatal and pediatric end-of-life situations.

DESIGN AND METHODS

This survey questionnaire was administered to interprofessional providers following their participation in an institutional workshop, as part of an ongoing institutional effort to improve end-of-life experiences for patients/family and providers. Interprofessional care providers completed an electronic survey consisting of closed-ended and one open-ended question to elicit their perceptions of their participation in end of life care for a recent neonatal/pediatric patient in the period before the child's death.

RESULTS

The qualitative analysis of 306 free-text responses commenting on the deaths of 138 patients, contained within 880 completed mixed-method surveys, is described. Thematic analysis of the free text discovered three primary themes from the data: favorable aspects of the death experience, unfavorable aspects of the experience, and combined favorable and unfavorable aspects. Four subthemes contributed to the themes; namely, language, parental presence, trust/rapport in provider relationships and inclusion in decision-making, communication, and culture.

CONCLUSIONS

Multiple factors contribute to how interprofessional care providers perceive end-of-life care experiences for neonatal/pediatric patients. The same death may be perceived differently by different providers.

PRACTICE IMPLICATIONS

Understanding favorable and unfavorable aspects of providing end-of-life care will support strategies to provide resources, education and support to facilitate coping and resiliency in care providers.

Barriers to Staff Involvement in End-of-Life Decision-Making for Long-Term Care Residents with Dementia

ABSTRACTAlthough providing direct care to residents with dementia, long-term care (LTC) home staff of registered nurses', registered practical nurses', and personal support workers' involvement in end-of-life decision-making is rarely acknowledged. The purpose of this study was to examine barriers and facilitators to LTC home staff involvement in end-of-life decision-making for people with advanced dementia. We report on the barriers to staff involvement in decision-making. Using an interpretive descriptive design, four major barriers to staff involvement in decision-making were identified: (a) the predominance of a biomedical model of care; (b) a varied understanding of a palliative approach; (c) challenging relationships with families; and (d) a discomfort with discussing death. Findings suggest that the predominant biomedical model in LTC homes, while important, must be imbued with a philosophy that emphasizes relationships among residents with dementia, family and staff.

Cultivating Knowing and Relationships: Nursing Assistants’ Interactions With Residents Receiving Palliative Care

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.

Protocol for a participatory study for developing qualitative instruments measuring the quality of long-term care relationships

INTRODUCTION

In long-term care (LTC), it is unclear which qualitative instruments are most effective and useful for monitoring the quality of the care relationship from the client's perspective. In this paper, we describe the research design for a study aimed at finding and optimising the most suitable and useful qualitative instruments for monitoring the care relationship in LTC.

METHODS AND ANALYSIS

The study will be performed in three organisations providing care to the following client groups: physically or mentally frail elderly, people with mental health problems and people with intellectual disabilities. Using a participatory research method, we will determine which determinants influence the quality of a care relationship and we will evaluate up to six instruments in cooperation with client-researchers. We will also determine whether the instruments (or parts thereof) can be applied across different LTC settings.

ETHICS AND DISSEMINATION

This study protocol describes a participatory research design for evaluating the quality of the care relationship in LTC. The Medical Ethics Committee of the Radboud University Nijmegen Medical Centre decided that formal approval was not needed under the Dutch Medical Research Involving Human Subjects Act. This research project will result in a toolbox and implementation plan, which can be used by clients and care professionals to measure and improve the care relationship from the client's perspective. The results will also be published in international peer-reviewed journals.

Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation

This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.

The Association Between Assisted Living Direct Care Worker End-of-Life Training and Hospice Use Patterns

As resident acuity levels increase for those who reside in assisted living (AL), states allow for hospice care provision in AL. End-of-life care training for staff can potentially increase the awareness of benefits of hospice care for AL residents. This study examined the association between AL staff trained in end-of-life care and hospice utilization in a sample of ALs (n = 45) in Florida. The sample included ALs (n = 21) with a low percentage (≤59%) and ALs (n = 24) with a high percentage (≥60%) of staff trained in end-of-life care as reported by AL directors. Zero-inflated negative binomial regression (ZINB) indicated that ALs in the high percentage of staff trained group were associated with a 3.64% greater utilization of hospice than ALs in the low percentage of staff trained group. Implementation of required staff training specific to care for the terminally ill as required in some states could potentially improve resident access to hospice care.

The Role of Assisted Living Capacity on Nursing Home Financial Performance

The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.

Shared decision-making at the end of life: A focus group study exploring the perceptions and experiences of multi-disciplinary healthcare professionals working in the home setting

BACKGROUND

Globally recommended in healthcare policy, Shared Decision-Making is also central to international policy promoting community palliative care. Yet realities of implementation by multi-disciplinary healthcare professionals who provide end-of-life care in the home are unclear.

AIM

To explore multi-disciplinary healthcare professionals' perceptions and experiences of Shared Decision-Making at end of life in the home.

DESIGN

Qualitative design using focus groups, transcribed verbatim and analysed thematically.

SETTING/PARTICIPANTS

A total of 43 participants, from multi-disciplinary community-based services in one region of the United Kingdom, were recruited.

RESULTS

While the rhetoric of Shared Decision-Making was recognised, its implementation was impacted by several interconnecting factors, including (1) conceptual confusion regarding Shared Decision-Making, (2) uncertainty in the process and (3) organisational factors which impeded Shared Decision-Making.

CONCLUSION

Multiple interacting factors influence implementation of Shared Decision-Making by professionals working in complex community settings at the end of life. Moving from rhetoric to reality requires future work exploring the realities of Shared Decision-Making practice at individual, process and systems levels.

Measuring Family Members' Satisfaction with End-of-Life Care in Long-Term Care: Adaptation of the CANHELP Lite Questionnaire

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.

Still Searching: A Meta-Synthesis of a Good Death from the Bereaved Family Member Perspective

The concept of a good death continues to receive attention in end-of-life (EOL) scholarship. We sought to continue this line of inquiry related to a good death by conducting a meta-synthesis of published qualitative research studies that examined a good death from the bereaved family member's perspective. Results of the meta-synthesis included 14 articles with 368 participants. Based on analysis, we present a conceptual model called The Opportunity Model for Presence during the EOL Process. The model is framed in socio-cultural factors, and major themes include EOL process engagement with categories of healthcare participants, communication and practical issues. The second theme, (dis)continuity of care, includes categories of place of care, knowledge of family member dying and moment of death. Both of these themes lead to perceptions of either a good or bad death, which influences the bereavement process. We argue the main contribution of the model is the ability to identify moments throughout the interaction where family members can be present to the EOL process. Recommendations for healthcare participants, including patients, family members and clinical care providers are offered to improve the quality of experience throughout the EOL process and limitations of the study are discussed.

Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life

Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

BACKGROUND

Care in nursing homes (NHs) often overlooks individual values and preferences. Residents' voices are critical to discussions about preferences, yet there remains limited research on conversations about the end of life (EOL) from the perspective of older adults who reside in NHs.

OBJECTIVE

The aim of this study was to describe the communication, content and process, related to EOL conversations among residents, family, and staff.

METHODS

We used semistructured interviews in this qualitative, descriptive study to describe conversations about EOL preferences. We examined participants' conversation, when it occurred, and what was discussed. We queried about barriers to and facilitators in discussing EOL care in the NH setting. We interviewed residents (n=16), family (n=12), and interdisciplinary staff (n=10) from four NHs.

RESULTS

The overarching theme—missed conversations—describes EOL-related communication. Residents, families, and staff rarely talked about EOL care preferences, nor did they pass along information about preferences or initiate conversations about EOL care with each other. Three categories explained missed conversations: inquiry ("No one asked"); assumptions (presence of an advance directive [AD], "They know me"); and conveying (lack of conveying information or wishes). Existing barriers and lacking facilitators resulted in missed opportunities to hold conversations about EOL preferences.

CONCLUSIONS

Not all residents wanted to have conversations, but many wanted to be asked about their preferences. Missed conversations may adversely affect the quality of EOL care. Conversations with residents can be initiated by asking residents who they would like involved in the conversation and drawing upon the experience of others.

Nursing home practices following resident death: the experience of Certified Nursing Assistants

This study examined certified nursing assistants' (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident's body, filling the bed with a new resident, and how they were notified about the death. The facilities' practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience.

Development of the Health Literacy of Caregivers Scale - Cancer (HLCS-C): item generation and content validity testing

BACKGROUND

Health literacy refers to an individual's ability to engage with health information and services. Cancer caregivers play a vital role in the care of people with cancer, and their capacity to find, understand, appraise and use health information and services influences how effectively they are able to undertake this role. The aim of this study was to develop an instrument to measure health literacy of cancer caregivers.

METHOD

Content areas for the new instrument were identified from a conceptual model of cancer caregiver health literacy. Item content was guided by statements provided by key stakeholders during consultation activities and selected to be representative across the range of cancer caregiver experiences. Content validity of items was assessed through expert review (n = 7) and cognitive interviews with caregivers (n = 16).

RESULTS

An initial pool of 82 items was generated across 10 domains. Two categories of response options were developed for these items: agreement with statements, and difficulty undertaking presented tasks. Expert review revealed that the majority of items were relevant and clear (Content Validity Index > 0.78). Cognitive interviews with caregivers suggested that all except three items were well understood.

CONCLUSION

A resultant 88 item questionnaire was developed to assess cancer caregiver health literacy. Further work is required to assess the construct validity and reliability of the new measure, and to remove poorly performing and redundant items, which will result in a shorter, final measure. The new measure has the potential to inform the development and evaluation of interventions and the improvement of health service delivery to cancer caregivers.

Family Members' Experience With Hospice in Nursing Homes

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.

Predictors of six-month mortality among nursing home residents: diagnoses may be more predictive than functional disability

OBJECTIVE

Loss of daily living functions can be a marker for end of life and possible hospice eligibility. Unfortunately, data on patient's functional abilities is not available in all settings. In this study we compare predictive accuracy of two indices designed to predict 6-month mortality among nursing home residents. One is based on traditional measures of functional deterioration and the other on patients' diagnoses and demography.

METHODS

We created the Hospice ELigibility Prediction (HELP) Index by examining mortality of 140,699 Veterans Administration (VA) nursing home residents. For these nursing home residents, the available data on history of hospital admissions were divided into training (112,897 cases) and validation (27,832 cases) sets. The training data were used to estimate the parameters of the HELP Index based on (1) diagnoses, (2) age on admission, and (3) number of diagnoses at admission. The validation data were used to assess the accuracy of predictions of the HELP Index. The cross-validated accuracy of the HELP Index was compared with the Barthel Index (BI) of functional ability obtained from 296,052 VA nursing home residents. A receiver operating characteristic curve was used to examine sensitivity and specificity of the predicted odds of mortality.

RESULTS

The area under the curve (AUC) for the HELP Index was 0.838. This was significantly (α <0.01) higher than the AUC for the BI of 0.692.

CONCLUSIONS

For nursing home residents, comorbid diagnoses predict 6-month mortality more accurately than functional status. The HELP Index can be used to estimate 6-month mortality from hospital data and can guide prognostic discussions prior to and following nursing home admission.

End-of-life expectations and experiences among nursing home patients and their relatives--a synthesis of qualitative studies

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.

"This is our last stop": Negotiating end-of-life transitions in assisted living

Where people die has important implications for end-of-life (EOL) care. Assisted living (AL) increasingly is becoming a site of EOL care and a place where people die. AL residents are moving in older and sicker and with more complex care needs, yet AL remains largely a non-medical care setting that subscribes to a social rather than medical model of care. The aims of this paper are to add to the limited knowledge of how EOL is perceived, experienced, and managed in AL and to learn how individual, facility, and community factors influence these perceptions and experiences. Using qualitative methods and a grounded theory approach to study eight diverse AL settings, we present a preliminary model for how EOL care transitions are negotiated in AL that depicts the range of multilevel intersecting factors that shape EOL processes and events in AL. Facilities developed what we refer to as an EOL presence, which varied across and within settings depending on multiple influences, including, notably, the dying trajectories and care arrangements of residents at EOL, the prevalence of death and dying in a facility, and the attitudes and responses of individuals and facilities toward EOL processes and events, including how deaths were communicated and formally acknowledged and the impact of death and dying on the residents and staff. Our findings indicate that in the majority of cases, EOL care must be supported by collaborative arrangements of care partners and that hospice care is a critical component.

Blended e-learning and end of life care in nursing homes: a small-scale mixed-methods case study

Background

A ‘blended’ (e-learning and facilitated workshops) training course for Group C staff (i.e. staff with relatively infrequent contact with end of life care) has been delivered across several English counties with the aim of improving end of life care in nursing and residential care homes. This paper evaluates the impact of the course on participants’ understandings of and confidence in delivering end of life care in one nursing home, while also considering barriers to change in practice.

Methods

A mixed-methods case study approach, incorporating pre- and post-course questionnaires (SHA East of England End of Life Care Education Programme ‘ABC’ Project Work Force C or Non Nurse Workforce B Pre and Post Course Questionnaire; E-Learning in End of Life Care Study Pre and Post Course Questionnaire), documentary analysis, semi-structured interviews, and observation of course workshops. Participants were 20 members of staff at a nursing home in a city in the East of England, including 14 Health Care Assistants (carers) and 6 others (administrative, activities, hosting, and catering staff). The questionnaires and interviews assessed understandings of and confidence towards end of life care delivery.

Results

Improvements in participants’ confidence in delivering end of life care were observed, particularly in the core competency areas of symptom management, communication, and advance care planning. A shift towards more detailed and more holistic understandings of end of life care was in evidence; some participants also championed end of life care in the home as a result of the course. Several barriers to changes in practice were encountered, including uneven participation, the absence of mechanisms for disseminating new insights and knowledge within the home, and a widespread perception that nurses’ professional dominance in the home made sustainable change difficult to enact.

Conclusions

While blended e-learning courses have the potential to generate positive change in participants’ understandings of and confidence about End of Life Care, organizational and inter-professional obstacles must be overcome in order to translate these changes into improved end of life care delivery in nursing (and residential) homes.

National hospice survey results: for-profit status, community engagement, and service

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P &lt; .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Racial Disparities in Receipt of Hospice Services Among Nursing Home Residents

This study examined the relationship between race and advance care planning, hospitalization, and death among nursing home residents receiving hospice care. Secondary data analysis using the 2007 Minimum Data Set (MDS) was used to identify documentation of these activities for White, Black, Hispanic, and Asian residents with linear regression models fitted to each dependent variable. Across different types of advance directives, compared to White nursing home residents, Black, Hispanic, and Asian residents who received hospice services were significantly less likely overall to have documented advance directives. All racial groups were also more likely to experience hospitalization while on hospice, regardless of whether they had a documented “do not hospitalize” order. As nursing homes become more diverse, recognizing differences in hospice use and end-of-life planning will continue to increase in importance.

Hospice use and public expenditures at the end of life in assisted living residents in a Florida Medicaid waiver program

OBJECTIVES

To examine the association between hospice use and public expenditures in a sample of dually eligible assisted living (AL) residents at the end of life.

DESIGN

A retrospective cohort study.

SETTING

Florida AL facilities.

PARTICIPANTS

Newly enrolled dually eligible older AL residents under Florida's Medicaid Assisted Living for the Elderly waiver program who died between January 2003 and December 2004 (N = 382).

MEASUREMENTS

Individual sociodemographic characteristics were obtained from Florida's Medicaid comprehensive assessment data. Medicaid eligibility status, enrollment in the AL waiver programs, International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Medicaid claims data were obtained from Florida's Medicaid payment agency. Individual characteristics and Medicare and Medicaid claims data were merged with vital statistics to determine diagnoses, date of death, hospice enrollment, and public expenditures.

RESULTS

The mean age of the study sample was 84.8 (range 65-102); 71.5% were female, and 63.4% were white. During the average 9.6 months of follow-up, 35.6% of the sample enrolled in hospice, and the average hospice length of stay was 47.9 d; 73.3% of the sample had been admitted to a hospital, and 38.0% had been admitted to a nursing home. The generalized linear model showed that hospice use was not significantly associated with lower public expenditures (average marginal effect = -$1,127, 95% confidence interval = -$8,377, $6,122).

CONCLUSION

Hospice use at the end of life may not be associated with lower public expenditures in older dually eligible AL residents. Future research should examine the association between hospice enrollment and the quality of end-of-life care.

Hospice use among nursing home patients

OBJECTIVES

Among hospice patients who lived in nursing homes, we sought to: (1) report trends in hospice use over time, (2) describe factors associated with very long hospice stays (>6 months), and (3) describe hospice utilization patterns.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective study from an urban, Midwest cohort of hospice patients, aged ≥ 65 years, who lived in nursing homes between 1999 and 2008.

MEASUREMENTS

Demographic data, clinical characteristics, and health care utilization were collected from Medicare claims, Medicaid claims, and Minimum Data Set assessments. Patients with overlapping nursing home and hospice stays were identified. χ(2) and t tests were used to compare patients with less than or longer than a 6-month hospice stay. Logistic regression was used to model the likelihood of being on hospice longer than 6 months.

RESULTS

A total of 1452 patients received hospice services while living in nursing homes. The proportion of patients with noncancer primary hospice diagnoses increased over time; the mean length of hospice stay (114 days) remained high throughout the 10-year period. More than 90% of all patients had 3 or more comorbid diagnoses. Nearly 20% of patients had hospice stays longer than 6 months. The hospice patients with stays longer than 6 months were observed to have a smaller percentage of cancer (25% vs 30%) as a primary hospice diagnosis. The two groups did not differ by mean cognitive status scores, number of comorbidities, or activities of daily living impairments. The greater than 6 months group was much more likely to disenroll before death: 33.9% compared with 13.8% (P < .0001). A variety of patterns of utilization of hospice across settings were observed; 21% of patients spent some of their hospice stay in the community.

CONCLUSIONS

Any policy proposals that impact the hospice benefit in nursing homes should take into account the difficulty in predicting the clinical course of these patients, varying utilization patterns and transitions across settings, and the importance of supporting multiple approaches for delivery of palliative care in this setting.

Influence of hospice on nursing home residents with advanced dementia who received Medicare-skilled nursing facility care near the end of life

OBJECTIVES

To examine differences in outcomes according to hospice status of skilled nursing facility (SNF) care recipients.

DESIGN

Retrospective cohort.

SETTING

Three thousand three hundred fifty-three U.S. nursing homes (NHs).

PARTICIPANTS

Four thousand three hundred forty-four persons with advanced dementia who died in NHs in 2006 and received SNF care within 90 days of death were studied, 1,086 of these also received hospice before death: 705 after SNF care, and 381 concurrent with SNF care.

MEASUREMENTS

Treatments, persistent pain and dyspnea, and hospital death.

RESULTS

Decedents with any hospice received fewer medications, injections, feeding tubes, intravenous fluids, and therapy services and more hypnotics than those without hospice (all P < .001). Decedents with hospice after SNF care received fewer antipsychotics and those with hospice concurrent with SNF care received more antipsychotics than those without (all P < .001). Multivariate logistic regressions showed that decedents with hospice after SNF had lower likelihood of persistent dyspnea (adjusted odds ratio (AOR) = 0.63, 95% confidence interval (CI) = 0.45-0.87) and hospital death (AOR = 0.02, 95% = CI 0.01, 0.07) than those without hospice. Decedents with hospice concurrent with SNF care had a higher likelihood of persistent pain (AOR = 1.65, 95% CI = 1.23, 2.19) and a lower likelihood of hospital death (AOR = 0.13, 95% CI = 0.07, 0.26) than those without hospice.

CONCLUSION

Residents dying with advanced dementia who received SNF care in the last 90 days of life had fewer aggressive treatments and lower odds of hospital death if they also received hospice care at any point during that time. Associations between hospice and persistent pain or dyspnea differed according to whether hospice care was received concurrent with or after SNF care.

End of Life in Residential Care from the Perspective of Care Aides

Nous 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.

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.

Long-distance caregiving: a systematic review of the literature

There are an estimated 5-7 million long-distance caregivers (LDCs) in the United States, but little is known about this growing population. This study reviewed the literature on LDCs and examined 16 identified studies. Although studies defined LDCs differently, a composite description of who LDCs are and what they do is presented. LDCs make substantial contributions in terms of physical, financial, and social support. Distance complicates communication about care recipients' health and care needs, as well as the types of care that can be provided. Related to this, geographic separation can exacerbate care-related stressors. Implications for future research were also identified.

Family Satisfaction With Care Provided by Nurse Practitioners to Nursing Home Residents With Dementia at the End of Life

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.

Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?

BACKGROUND

Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital.

METHODS

This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital.

RESULTS

Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short (≤7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025).

CONCLUSIONS

Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.