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Toles M, Kistler C, Lin FC, Lynch M, Wessell K, Mitchell SL, Hanson LC. Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial. Trials 2023; 24:606. [PMID: 37743478 PMCID: PMC10518941 DOI: 10.1186/s13063-023-07614-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program. METHODS The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage. DISCUSSION The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care. TRIAL REGISTRATION ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.
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Affiliation(s)
- M Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - C Kistler
- Department of Family Medicine and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F C Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Lynch
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - L C Hanson
- Division of Geriatrics and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Nicholson CJ, Combes S, Mold F, King H, Green R. Addressing inequity in palliative care provision for older people living with multimorbidity. Perspectives of community-dwelling older people on their palliative care needs: A scoping review. Palliat Med 2022; 37:475-497. [PMID: 36002975 PMCID: PMC10074761 DOI: 10.1177/02692163221118230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Older people living with multimorbidity are projected to become the main recipients of palliative care in the coming decades, yet there is limited evidence regarding their expressed palliative care needs to inform person-centred care. AIM To understand the palliative care needs of community-dwelling people aged ⩾60 living with multimorbidity in the last 2 years of life. DESIGN A scoping review following Arksey and O'Malley. DATA SOURCES Three international electronic databases (CINAHL, Ovid Medline, PsycINFO) were searched from March 2018 to December 2021. Reference lists were hand searched. Eligible papers were those reporting empirical data on older people's needs. RESULTS From 985 potential papers, 28 studies were included, published between 2002 and 2020; sixteen quantitative, nine qualitative and three mixed methods. Data were extracted and presented under the holistic palliative care domains of need: physical, psychological, social, spiritual, and additionally practical needs. Different measurement tools (n = 29) were used, of which 20 were multidimensional. Primacy in reporting was given to physical needs, most commonly pain and function. Social and practical needs were often prioritised by older people themselves, including maintaining social connections and accessing and receiving individualised care. CONCLUSION Identifying the palliative care needs that matter most to older people with multimorbidity requires the recognition of their concerns, as well as their symptoms, across a continuum of living and dying. Available evidence is superficial. Supporting end of life provision for this growing and underserved population necessitates a shift to tailored multidimensional tools and community focussed integrated care services.
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Affiliation(s)
| | - Sarah Combes
- University of Surrey, Guildford, UK
- St Christopher's Hospice, London, UK
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Hovland CA, Fuller KA. African American Family Caregivers Share How they Prepared for the Death of an Older Adult with Dementia: A Pilot Study of Hospice Care in A Nursing Home. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2022; 18:129-145. [PMID: 35226595 DOI: 10.1080/15524256.2022.2042458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The focus of this pilot study was to ascertain how bereaved African American caregivers prepared for the death of an older family member who died from a dementia-related diagnosis and the role of hospice care; an area with little research to date. Because African American older adults in the United States are at greater risk than Caucasian older adults for dementia-related health problems though less likely to be diagnosed, treated, or to enroll in hospice services, this exploratory study asked questions of the family caregivers' experiences in preparing for the death. Purposive criterion sampling was used to identify six African American bereaved caregivers whose family member lived in a nursing home (five who were enrolled in hospice services) who were extensively interviewed, with the use of conventional content analysis of the transcripts to identify the findings. Because of the limited sample size, themes identified were considered preliminary and may help guide ongoing and further research. Five primary themes revealed ways caregivers prepared: accepting reality; "I just kind of knew;" person with dementia "was ready;" "spending time;" and, getting your "business in order." All caregivers believed it was important to be prepared for the death, with the five who received hospice services reporting that they were prepared. Further research is needed to explore these preliminary findings of African American caregivers of family members with dementia at end-of-life to further inform social work and hospice team care.
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Affiliation(s)
- Cynthia A Hovland
- School of Social Work, Cleveland State University, Cleveland, Ohio, USA
| | - Kimberly A Fuller
- School of Social Work, Cleveland State University, Cleveland, Ohio, USA
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Ding J, Johnson CE, Lee YCO, Gazey A, Cook A. Characteristics of People with Dementia vs Other Conditions on Admission to Inpatient Palliative Care. J Am Geriatr Soc 2020; 68:1825-1833. [PMID: 32329901 DOI: 10.1111/jgs.16458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our aim was to (1) describe the clinical characteristics and symptoms of people diagnosed with dementia at the time of admission to inpatient palliative care; and (2) compare the nature and severity of these palliative care-related problems to patients with other chronic diseases. DESIGN Descriptive study using assessment data on point of care outcomes (January 1, 2013, to December 31, 2018). SETTING A total of 129 inpatient palliative care services participating in the Australian Palliative Care Outcomes Collaboration. PARTICIPANTS A total of 29,971 patients with a primary diagnosis of dementia (n = 1,872), lung cancer (n = 19,499), cardiovascular disease (CVD, n = 5,079), stroke (n = 2,659), or motor neuron disease (MND, n = 862). MEASUREMENTS This study reported the data collected at the time of admission to inpatient palliative care services including patients' self-rated levels of distress from seven common physical symptoms, clinician-rated symptom severity, functional dependency, and performance status. Other data analyzed included number of admissions, length of inpatient stay, and palliative care phases. RESULTS At the time of admission to inpatient palliative care services, relative to patients with lung cancer, CVD, and MND, people with dementia presented with lower levels of distress from most symptoms (odds ratios [ORs] range from .15 to .80; P < .05 for all) but higher levels of functional impairment (ORs range from 3.02 to 8.62; P < .001 for all), and they needed more assistance with basic activities of daily living (ORs range from 3.83 to 12.24; P < .001 for all). The trends were mostly the opposite direction when compared with stroke patients. Patients with dementia tended to receive inpatient palliative care later than those with lung cancer and MND. CONCLUSION The unique pattern of palliative care problems experienced by people with dementia, as well as the skills of the relevant health services, need to be considered when deciding on the best location of care for each individual. Access to appropriately trained palliative care clinicians is important for people with high levels of physical or psychological concerns, irrespective of the care setting or diagnosis. J Am Geriatr Soc 68:1825-1833, 2020.
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Affiliation(s)
- Jinfeng Ding
- School of Population and Global Health, The University of Western Australia, Crawley, Australia
| | - Claire E Johnson
- Monash Nursing and Midwifery, Monash University, Clayton, Australia.,Supportive and Palliative Care, Eastern Health, Victoria, Australia.,Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia.,Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Australia
| | | | - Angela Gazey
- School of Population and Global Health, The University of Western Australia, Crawley, Australia
| | - Angus Cook
- School of Population and Global Health, The University of Western Australia, Crawley, Australia
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Hoffmann F, Allers K. [Hospitalization of nursing home residents in the last phase of life: an analysis of health insurance data]. Z Gerontol Geriatr 2020; 54:247-254. [PMID: 32185465 PMCID: PMC8096747 DOI: 10.1007/s00391-020-01716-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 03/03/2020] [Indexed: 11/30/2022]
Abstract
Hintergrund Im internationalen Vergleich versterben Pflegeheimbewohner in Deutschland häufig im Krankenhaus. Daten zu längeren Zeiträumen vor dem Tod und zu regionalen Unterschieden fehlen. Ziel der Arbeit Es werden Häufigkeiten von Krankenhausaufenthalten bei Pflegeheimbewohnern in verschiedenen Perioden vor dem Tod analysiert. Zudem werden Unterschiede nach Alter, Geschlecht, Pflegestufe, Demenz und Bundesländern untersucht. Material und Methoden Wir verwendeten Daten einer großen Krankenkasse und schlossen Pflegeheimbewohner im Mindestalter von 65 Jahren ein, die zwischen dem 01.01.2010 und dem 31. 12.2014 verstarben. Outcome war mindestens ein Krankenhausaufenthalt nach Heimeintritt in verschiedenen Phasen des letzten Lebensjahres. Vertiefende Analysen wurden für die Zeiträume 0 (entspricht Versterben im Krankenhaus), 28 und 365 Tage vor Tod durchgeführt. Ergebnisse Von den insgesamt 67.328 verstorbenen Bewohnern (mittleres Alter: 85,3 Jahre; 69,8 % weiblich), verstarben 29,5 % im Krankenhaus. In den letzten 28 bzw. 365 Tagen vor Tod hatten 51,5 % bzw. 74,3 % mindestens einen Krankenhausaufenthalt. Diese Werte waren in ostdeutschen Bundesländern höher. In allen Zeiträumen wurden Männer häufiger hospitalisiert. Bewohner mit höherer Pflegestufe wurden seltener stationär behandelt, besonders unmittelbar vor dem Tod. Demenz hatte keinen nennenswerten Einfluss auf die Hospitalisierungshäufigkeiten. Diskussion Etwa die Hälfte der Pflegeheimbewohner wird im letzten Lebensmonat stationär behandelt, und ein Drittel verstirbt im Krankenhaus, was, international betrachtet, hoch ist. Dass wir keine Unterschiede bei Bewohnern mit und ohne Demenz fanden, widerspricht ebenso internationalen Befunden. Somit besteht erheblicher Handlungsbedarf, die palliative Versorgung von Pflegeheimbewohnern zu optimieren.
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Affiliation(s)
- Falk Hoffmann
- Department für Versorgungsforschung, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Deutschland.
| | - Katharina Allers
- Department für Versorgungsforschung, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Deutschland
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Abstract
BACKGROUND End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Rieke Schnakenberg
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Hoffmann F, Strautmann A, Allers K. Hospitalization at the end of life among nursing home residents with dementia: a systematic review. BMC Palliat Care 2019; 18:77. [PMID: 31506100 PMCID: PMC6737675 DOI: 10.1186/s12904-019-0462-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/06/2019] [Indexed: 12/24/2022] Open
Abstract
Background Half of nursing home residents (NHR) suffer from dementia. End-of-life hospitalizations are often burdensome in residents with dementia. A systematic review was conducted to study the occurrence of hospitalizations at the end of life in NHR with dementia and to compare these figures to NHR without dementia. Methods A systematic literature search in MEDLINE, CINAHL and Scopus was conducted in May 2018. Studies were included if they reported proportions of in-hospital deaths or hospitalizations of NHR with dementia in the last month of life. Two authors independently selected studies, extracted data, and assessed quality of studies. Results Nine hundred forty-five citations were retrieved; 13 studies were included. Overall, 7 studies reported data on in-hospital death with proportions ranging between 0% in Canada and 53.3% in the UK. Studies reporting on the last 30 days of life (n = 8) varied between 8.0% in the Netherlands and 51.3% in Germany. Two studies each assessed the influence of age and sex. There seem to be fewer end-of-life hospitalizations in older age groups. The influence of sex is inconclusive. All but one study found that at the end of life residents with dementia were hospitalized less often than those without (n = 6). Conclusions We found large variations in end-of-life hospitalizations of NHR with dementia, probably being explained by differences between countries. The influence of sex and age might differ when compared to residents without dementia. More studies should compare NHR with dementia to those without and assess the influence of sex and age. Trial registration PROSPERO registration number CRD42018104263.
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Affiliation(s)
- Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany.
| | - Anke Strautmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany
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Hoffmann F, Allers K. Dying in hospital among nursing home residents with and without dementia in Germany. Arch Gerontol Geriatr 2019; 82:293-298. [PMID: 30909116 DOI: 10.1016/j.archger.2019.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Nursing home residents (NHR) often suffer from dementia. As end-of-life care of NHR with dementia and without might differ, our aim was to investigate patterns of in-hospital deaths in NHR with and without dementia. DESIGN Retrospective observational study. SETTING German nursing homes. PARTICIPANTS Deceased NHR. MEASUREMENTS Using data of a large German health insurance fund, we included NHR aged 65+ years who died between January 1, 2010, and December 31, 2014. We assessed proportions of in-hospital deaths stratified by dementia status as well as by age, sex, level of care and length of stay. Multiple logistic regression models were applied to explore the association of these variables with in-hospital death. RESULTS Data on 67,328 decedents were included (mean age 85.3 years, 69.8% female), of whom 43.1% suffered from dementia. Overall, 29.5% died in hospital, with similar figures found for those with dementia (29.2%) and those without (29.8%). Differences between NHR with and without dementia were noticeable regarding age and length of stay. In those with dementia, the proportion of in-hospital deaths decreased linearly with age from 37.0%-20.2% (65-74 to 95+ years). These results are supported by the multivariate analyses. The terminal hospital stay was up to 3 days in 32.6%. This length did not differ by dementia status. CONCLUSIONS Germany has a high proportion of NHR in-hospital deaths. Surprisingly, we found no differences in these figures between NHR with and without dementia, although predictors for in-hospital death seem to differ between these groups.
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Affiliation(s)
- Falk Hoffmann
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany.
| | - Katharina Allers
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany
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Hovland CA, Kramer BJ. Barriers and Facilitators to Preparedness for Death: Experiences of Family Caregivers of Elders with Dementia. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2019; 15:55-74. [PMID: 30995886 DOI: 10.1080/15524256.2019.1595811] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Less is known about how caregivers prepare (or not) for the death of a family member with dementia. This study's purpose was to explore how caregivers handle these dementia deaths, including identification of barriers and facilitators to preparing caregivers for the death of an elder family member dying with dementia. This qualitative, descriptive study employed a purposive sampling strategy in which the principal investigator interviewed 36 caregivers of family members age 65 and older who died from a dementia-related diagnosis. Directed content analysis was used to analyze the data. Four primary themes were identified as barriers: (1) hindrances to information; (2) barriers to hospice; (3) ineffective attempts to comfort; and (4) the nature of death with dementia. Six themes were identified as facilitators: (1) religious/spiritual beliefs; (2) caregiver initiative; (3) prior experience; (4) bearing witness to decline; (5) professionals alerting caregiver (of what to expect of impending death); and (6) culture and legacy of family caregiving. The results support an increased role of social work in addressing caregivers' awareness of impending death and helping prepare them for the death of an elder with dementia.
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Affiliation(s)
- Cynthia A Hovland
- a School of Social Work , Cleveland State University , Cleveland , Ohio , USA
| | - Betty J Kramer
- b School of Social Work , University of Wisconsin-Madison , Madison , Wisconsin , USA
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Allers K, Hoffmann F. Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia. Soc Psychiatry Psychiatr Epidemiol 2018; 53:833-839. [PMID: 29721593 DOI: 10.1007/s00127-018-1523-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/25/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE The proportion of deaths occurring in nursing homes is increasing and end of life hospitalizations in residents are common. This study aimed to obtain the time from nursing home admission to death and the frequency of hospitalizations prior to death among residents with and without dementia. METHODS This retrospective cohort study analyzed claims data of 127,227 nursing home residents aged 65 years and older newly admitted to a nursing home between 2010 and 2014. We analyzed hospitalizations during the last year of life and assessed mortality rates per 100 person-years. Factors potentially associated with time to death were analyzed in Cox proportional hazard models. RESULTS The median time from nursing home admission to death was 777 and 635 days in residents with and without dementia, respectively. Being male, older age and a higher level of care decreased the survival time. Sex and age had a higher influence on survival time in residents with dementia, whereas level of care was found to have a higher influence in residents without dementia. Half of the residents of both groups were hospitalized during the last month and about 37% during the last week before death. Leading causes of hospitalizations were infections (with dementia: 20.6% vs. without dementia: 17.2%) and cardiovascular diseases (with dementia: 16.6% vs. without dementia: 19.0%). CONCLUSIONS A high proportion of residents with and without dementia are hospitalized shortly before death. There should be an open debate about the appropriateness of hospitalizing nursing home residents especially those with dementia near death.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Hovland-Scafe CA, Kramer BJ. Preparedness for Death: How Caregivers of Elders With Dementia Define and Perceive its Value. THE GERONTOLOGIST 2018; 57:1093-1102. [PMID: 27342441 DOI: 10.1093/geront/gnw092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/20/2016] [Indexed: 11/14/2022] Open
Abstract
Purpose The purpose of this study is to ascertain how bereaved caregivers of a family member who died from a dementia-related diagnosis (a) define preparedness and (b) perceive its value. Design and Methods Purposive criterion sampling was employed to identify 30 bereaved caregivers of family members aged 65 and older who died with a dementia-related diagnosis. In-depth, qualitative interviews were conducted over a 12-month period, and qualitative content analysis was used to analyze the data. Results Only one third (n = 10) of caregivers interviewed were prepared for the death, and the majority who were prepared were enrolled in hospice. Five primary themes revealed ways that caregivers define various domains of preparedness: (i) accepting reality; (ii) knowing death is near; (iii) getting your "house in order"; (iv) saying "what you need to say"; and (v) giving "permission" to die. The majority (87%) believed that it is important for caregivers to be prepared, and the value of preparedness was exemplified in five domains reflecting the benefits of being prepared. Implications The results support further attention to the development and testing of interventions to address the unmet needs of caregivers of family members with dementia to help prepare them for the death in a variety of contexts.
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Ernecoff NC, Zimmerman S, Mitchell SL, Song MK, Lin FC, Wessell KL, Hanson LC. Concordance between Goals of Care and Treatment Decisions for Persons with Dementia. J Palliat Med 2018; 21:1442-1447. [PMID: 29957095 DOI: 10.1089/jpm.2018.0103] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nursing home (NH) residents with dementia experience high rates of intensive treatment near the end of life. Limited research examines whether treatment is concordant with goals of care (GOC). OBJECTIVES We analyzed data from the GOC trial to describe family decision makers' preferred GOC and perceptions of goal-concordant care for NH residents with late-stage dementia We compared subsequent treatment orders when families chose a primary goal of comfort versus other goals. DESIGN We performed a secondary analysis of data from baseline and 9-month family decision-maker interviews and chart reviews. SETTING AND PARTICIPANTS A total of 302 dyads of NH residents and family decision makers in 22 North Carolina NHs were enrolled. MEASUREMENTS In baseline and follow-up interviews, families reported on their and NH staff's primary GOC, and perceived prognosis and goal-concordant care. Chart reviews provided data on treatment orders, hospital transfers, and hospice, which were compared after selection of a primary goal of comfort versus other goals. RESULTS Family chose comfort as the primary goal for 66% of residents at baseline, and for nearly 80% by 9 months or death. At baseline, 49% perceived concordance with NH staff on the primary goal, and 69% at follow-up. In multivariate models, choice of comfort as the primary goal, versus other goals, was associated with half as many hospital transfers (0.11 vs. 0.25/90 person-days, confidence interval [-0.2 to -0.01]), but not with hospice or treatment orders. CONCLUSIONS Most families chose comfort as the primary GOC. Further research is needed to translate this preference into comfort-focused treatment plans for late-stage dementia. Clinicaltrials.gov : NCT01565642 (3/26/12).
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Affiliation(s)
- Natalie C Ernecoff
- 1 Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, North Carolina.,2 Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina , Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- 1 Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, North Carolina.,3 School of Social Work, University of North Carolina , Chapel Hill, North Carolina
| | - Susan L Mitchell
- 4 Harvard Medical School , Boston, Massachusetts.,5 Hebrew SeniorLife , Boston, Massachusetts
| | - Mi-Kyung Song
- 6 Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University , Atlanta, Georgia
| | - Feng-Chang Lin
- 1 Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, North Carolina.,7 Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina , Chapel Hill, North Carolina
| | - Kathryn L Wessell
- 1 Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, North Carolina
| | - Laura C Hanson
- 1 Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, North Carolina.,8 Division of Geriatric Medicine and Palliative Care Progam, University of North Carolina , Chapel Hill, North Carolina
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End of Life Care: A Scoping Review of Experiences of Advance Care Planning for People with Dementia. DEMENTIA 2016; 18:825-845. [DOI: 10.1177/1471301216676121] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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Morin L, Johnell K, Van den Block L, Aubry R. Discussing end-of-life issues in nursing homes: a nationwide study in France. Age Ageing 2016; 45:395-402. [PMID: 27013503 DOI: 10.1093/ageing/afw046] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 12/23/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life. OBJECTIVES this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life. METHODS post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674). RESULTS end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08-0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33-0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29). CONCLUSION during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden French National Observatory on End-of-Life Care, Paris, France
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Lieve Van den Block
- VUB-UGent End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Régis Aubry
- French National Observatory on End-of-Life Care, Paris, France Department of Palliative Care, University Hospital of Besancon, Besançon, France
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Innes A, Kelly F, Scerri C, Abela S. Living with dementia in hospital wards: a comparative study of staff perceptions of practice and observed patient experience. Int J Older People Nurs 2016; 11:94-106. [PMID: 26786566 DOI: 10.1111/opn.12102] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 09/14/2015] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To ascertain the experiences, attitudes and knowledge of staff working in two Maltese hospital wards and the observed experiences of people with dementia living there. To examine the impact of recommendations made in October 2011 for improving the psychosocial and physical environments of the wards 1 year later. BACKGROUND There is an increasing policy recognition of the need for a better trained and educated dementia care workforce and of ensuring that the environmental design of care settings meets the needs of people with dementia. DESIGN AND METHODS At both time points, three established and validated data-collection methods evaluated (i) staff/patient interaction and patient experience, (ii) the extent to which the wards met dementia friendly principles and (iii) staff views about their work environment and their perceptions about their practice. Sixteen (five male and 11 female) patients with dementia and 69 staff in the two wards participated in the study. RESULTS We noted small but important changes; however, the physical and psychosocial environments of the wards did not always align to current recommendations for dementia care, with staff perceptions of care delivery not always reflecting the observed experiences of care of those living with dementia. CONCLUSIONS Comparing staff questionnaire data with observational methods offered a unique opportunity to understand multiple perspectives in a complex hospital setting. Incorporating these perspectives into staff and management feedback allowed for recommendations that recognised both patient-centred values and staff constraints.
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Affiliation(s)
- Anthea Innes
- School of Health, Nursing and Midwifery, Institute for Healthcare Policy and Practice, Hamilton Campus, Hamilton ML3 0JB, Scotland
| | - Fiona Kelly
- Bournemouth University Dementia Institute, Bournemouth University, Bournemouth, UK
| | - Charles Scerri
- National Focal Point on Dementia, Department of Pathology, University of Malta, Msida, Malta
| | - Stephen Abela
- Department for the Elderly and Community Care, St. Venera, Malta
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Jethwa KD, Onalaja O. Advance care planning and palliative medicine in advanced dementia: a literature review. BJPsych Bull 2015; 39:74-8. [PMID: 26191437 PMCID: PMC4478901 DOI: 10.1192/pb.bp.114.046896] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 04/11/2014] [Accepted: 05/19/2014] [Indexed: 11/23/2022] Open
Abstract
Aims and method To assess the factors that affect the clinical use of advanced care planning and palliative care interventions in patients with dementia. A literature search of Medline, Embase and PsycINFO was performed to identify themes in advanced care planning and palliative care in dementia. Results In total, 64 articles were found, including 12 reviews, and three key areas emerged: barriers to advanced care planning, raising awareness and fostering communication between professionals and patients, and disease-specific interventions. Clinical implications Most of the studies analysed were carried out in the USA or Continental Europe. This narrative review aims to help guide future primary research, systematic reviews and service development in the UK.
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Affiliation(s)
- Ketan Dipak Jethwa
- University of Warwick and Coventry and Warwickshire Partnership NHS Trust
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Fariña-López E, Estévez-Guerra GJ, Gandoy-Crego M, Polo-Luque LM, Gómez-Cantorna C, Capezuti EA. Perception of spanish nursing staff on the use of physical restraints. J Nurs Scholarsh 2014; 46:322-30. [PMID: 24754778 DOI: 10.1111/jnu.12087] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine the perception of registered nurses and nursing assistants regarding the use of physical restraints with residents of nursing homes located in four of the regions of Spain; and to evaluate the relationship of these perceptions to the staff respondents' level of training. DESIGN Cross-sectional multicenter and correlational study. The research was conducted in 2013 in 19 Spanish nursing homes with 2,940 residential beds. A total of 785 nurses (170 registered nurses and 615 nursing assistants) participated in the study. METHODS The Perception of Restraint Use Questionnaire (PRUQ), consisting of 17 of the most cited reasons for using these devices, was used, as was a questionnaire capturing the sociodemographic characteristics and educational or experience level of staff respondents. FINDINGS Nurses reported the most important uses for restraints as prevention of falls and avoidance of medical device interference. As indicated by an average PRUQ score of 3.47, staff respondents supported restraint use, especially nursing assistants (3.59) as compared to registered nurses (3.00). With regard to training: 83.7% had participated in little, if any, training and only 29.2% had read three or more documents related to restraint use; 66.6% believed that their training was inadequate. No correlation was found between the results of the PRUQ and the respondents´ sociodemographic characteristics or participation in training activities. No differences were found among nurses by region. CONCLUSIONS In contrast to papers published in other countries, nurses in this study still consider it necessary to apply restraints in everyday practice. The education of nursing staff regarding restraint and knowledge of alternatives is needed; they should at least be aware of international standards of care regarding physical restraint use. CLINICAL RELEVANCE Most of the staff perceived their training related to the use of these devices as insufficient. Nursing assistants considered the use of restraints more important than did the registered nurses.
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Affiliation(s)
- Emilio Fariña-López
- Associate Professor, Nursing Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Implementation of a Facilitated Advance Care Planning Process in an Assisted Living Facility. J Hosp Palliat Nurs 2014. [DOI: 10.1097/njh.0000000000000033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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20
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Development and testing of a decision aid on goals of care for advanced dementia. J Am Med Dir Assoc 2014; 15:251-5. [PMID: 24508326 DOI: 10.1016/j.jamda.2013.11.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Decision aids are effective to improve decision-making, yet they are rarely tested in nursing homes (NHs). Study objectives were to (1) examine the feasibility of a goals of care (GOC) decision aid for surrogate decision-makers (SDMs) of persons with dementia; and (2) to test its effect on quality of communication and decision-making. DESIGN Pre-post intervention to test a GOC decision aid intervention for SDMs for persons with dementia in NHs. Investigators collected data from reviews of resident health records and interviews with SDMs at baseline and 3-month follow-up. SETTING Two NHs in North Carolina. PARTICIPANTS Eighteen residents who were over 65 years of age, had moderate to severe dementia on the global deterioration scale (5, 6, or 7), and an English-speaking surrogate decision-maker. INTERVENTION (1) GOC decision aid video viewed by the SDM and (2) a structured care plan meeting between the SDM and interdisciplinary NH team. MEASUREMENTS Surrogate knowledge, quality of communication with health care providers, surrogate-provider concordance on goals of care, and palliative care domains addressed in the care plan. RESULTS Eighty-nine percent of the SDMs thought the decision aid was relevant to their needs. After viewing the video decision aid, SDMs increased the number of correct responses on knowledge-based questions (12.5 vs 14.2; P < .001). At 3 months, they reported improved quality of communication scores (6.1 vs 6.8; P = .01) and improved concordance on primary goal of care with NH team (50% vs 78%; P = .003). The number of palliative care domains addressed in the care plan increased (1.8 vs 4.3; P < .001). CONCLUSIONS The decision-support intervention piloted in this study was feasible and relevant for surrogate decision-makers of persons with advanced dementia in NHs, and it improved quality of communication between SDM and NH providers. A larger randomized clinical trial is underway to provide further evidence of the effects of this decision aid intervention.
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Cadieux MA, Garcia LJ, Patrick J. Needs of people with dementia in long-term care: a systematic review. Am J Alzheimers Dis Other Demen 2013; 28:723-33. [PMID: 24005852 PMCID: PMC10852926 DOI: 10.1177/1533317513500840] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
With the aging of the population and the projected increase of dementia in the coming years, it is crucial that we understand the needs of people with dementia (PWD) in order to provide appropriate care. The aim of this study is to determine, using the best evidence possible, the care needs of PWD living in long-term care (LTC). A total of 68 studies, published between January 2000 and September 2010, were identified from six databases. From the selected studies, 19 needs of PWD were identified. The existing evidence suggests that psychosocial needs such as the need to engage in daily individualized activities and care must not be ignored in LTC. This review aims to provide a clearer picture of the needs of this growing patient population.
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Affiliation(s)
- Marie-Andrée Cadieux
- Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Linda J. Garcia
- Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jonathan Patrick
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
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Hanson LC, Winzelberg G. Research priorities for geriatric palliative care: goals, values, and preferences. J Palliat Med 2013; 16:1175-9. [PMID: 24007351 PMCID: PMC3837560 DOI: 10.1089/jpm.2013.9475] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2013] [Indexed: 01/05/2023] Open
Abstract
Older patients and their families desire control over health decisions in serious illness. Experts recommend discussion of prognosis and goals of care prior to decisions about treatment. Having achieved longevity, older persons often prioritize other goals such as function, comfort, or family support--and skilled communication is critical to shift treatment to match these goals. Shared decision making is the ideal approach in serious illness. Older patients desire greater family involvement; higher rates of cognitive impairment mean greater dependency on surrogates to make decisions. Despite the importance of communication, fewer than half of older patients or families recall treatment discussions with clinicians, and poor quality communication adversely affects family satisfaction and patient outcomes. Direct audiorecording of clinical encounters and longitudinal studies of communication and treatment decisions have yielded important insights into the quality of clinical communication. Current clinical practice rarely meets standards for shared decision making. Innovative methods to record and use patient preferences show promise to overcome the limitations of traditional advance directives. Decision aids, intensive clinician training, and structured interpersonal communication interventions have all been shown to be effective to improve the quality of communication and decision making. Priorities for geriatric palliative care research, building on these insights, now include empirical testing of communication approaches for surrogates and for diverse populations, exploration of meaningful ways to communicate prognosis, and expansion of intervention research.
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Affiliation(s)
- Laura C Hanson
- UNC Palliative Care Program, Division of Geriatric Medicine, University of North Carolina , Chapel Hill, North Carolina
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Iliffe S, Davies N, Vernooij-Dassen M, van Riet Paap J, Sommerbakk R, Mariani E, Jaspers B, Radbruch L, Manthorpe J, Maio L, Haugen D, Engels Y. Modelling the landscape of palliative care for people with dementia: a European mixed methods study. BMC Palliat Care 2013; 12:30. [PMID: 23937891 PMCID: PMC3751306 DOI: 10.1186/1472-684x-12-30] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 08/02/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Palliative care for people with dementia is often sub-optimal. This is partly because of the challenging nature of dementia itself, and partly because of system failings that are particularly salient in primary care and community services. There is a need to systematize palliative care for people with dementia, to clarify where changes in practice could be made.To develop a model of palliative care for people with dementia that captures commonalities and differences across Europe, a technology development approach was adopted, using mixed methods including 1) critical synthesis of the research literature and policy documents, 2) interviews with national experts in policy, service organisation, service delivery, patient and carer interests, and research in palliative care, and 3) nominal groups of researchers tasked with synthesising data and modelling palliative care. DISCUSSION A generic model of palliative care, into which quality indicators can be embedded. The proposed model includes features deemed important for the systematisation of palliative care for people with dementia. These are: the division of labour amongst practitioners of different disciplines; the structure and function of care planning; the management of rising risk and increasing complexity; boundaries between disease-modifying treatment and palliative care and between palliative and end-of-life care; and the process of bereavement. SUMMARY The co-design approach to developing a generic model of palliative care for people with dementia has placed the person needing palliative care within a landscape of services and professional disciplines. This model will be explored further in the intervention phase of the IMPACT project.
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Affiliation(s)
- Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, London, England
| | - Nathan Davies
- Research Department of Primary Care & Population Health, University College London, London, England
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jasper van Riet Paap
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ragni Sommerbakk
- Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elena Mariani
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Centre for Palliative Medicine, Malteser Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Jill Manthorpe
- Social Care Workforce Research Unit, Kings College London, London, England
| | - Laura Maio
- Research Department of Primary Care & Population Health, University College London, London, England
| | - Dagny Haugen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Yvonne Engels
- Department of anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Zimmerman S, Anderson WL, Brode S, Jonas D, Lux L, Beeber AS, Watson LC, Viswanathan M, Lohr KN, Sloane PD. Systematic review: Effective characteristics of nursing homes and other residential long-term care settings for people with dementia. J Am Geriatr Soc 2013; 61:1399-409. [PMID: 23869936 DOI: 10.1111/jgs.12372] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. DESIGN Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. RESULTS Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials (RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. CONCLUSION Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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Raymond M, Warner A, Davies N, Baishnab E, Manthorpe J, Iliffe S. Evaluating educational initiatives to improve palliative care for people with dementia: a narrative review. DEMENTIA 2013; 13:366-81. [PMID: 24339062 DOI: 10.1177/1471301212474140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dementia accounts for one in three deaths among people aged 65 and over, but end-of-life care for people with dementia is often sub-optimal. Palliative care for people with dementia poses particular challenges to those providing services, and current policy initiatives recommend education and training in palliative care for those working with patients with dementia. However, there are few evaluations of the effectiveness of dementia education and training. This paper presents a narrative review undertaken in 2011-2012 of evaluations of palliative care education for those working with people with dementia at the end of life. A total of eight papers were identified that described and evaluated such palliative care education; none reported benefits for people with dementia. There is a clear need to develop and evaluate educational interventions designed to improve palliative and end-of-life care for people with dementia. Some suggestions for educationally sound approaches are discussed.
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Zimmerman S, Cohen LW, Reed D, Gwyther LP, Washington T, Cagle JG, Beeber AS, Sloane PD. Comparing families and staff in nursing homes and assisted living: implications for social work practice. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2013; 56:535-53. [PMID: 23869592 PMCID: PMC3772131 DOI: 10.1080/01634372.2013.811145] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Nursing homes and residential care/assisted living settings provide care to 2.4 million individuals. Few studies compare the experience of, and relationships between, family and staff in these settings, despite ongoing family involvement and evidence that relationships are problematic. Data from 488 families and 397 staff members in 24 settings examined family involvement and family and staff burden, depressive symptoms, and perceptions; and staff absenteeism and turnover. There were few differences across setting types. Although conflict rarely occurred, there was room for improvement in family-staff relations; this area, and preparing family for their caregiving roles, are appropriate targets for social work intervention.
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Affiliation(s)
- Sheryl Zimmerman
- School of Social Work and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Snyder EA, Caprio AJ, Wessell K, Lin FC, Hanson LC. Impact of a decision aid on surrogate decision-makers' perceptions of feeding options for patients with dementia. J Am Med Dir Assoc 2012; 14:114-8. [PMID: 23273855 DOI: 10.1016/j.jamda.2012.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/14/2012] [Accepted: 10/19/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In advanced dementia, feeding problems are nearly universal, and families face difficult decisions about feeding options. Initial interviews for a randomized trial were used to describe surrogates' perceptions of feeding options, and to determine whether a decision aid on feeding options in advanced dementia would improve knowledge, reduce expectation of benefit from tube feeding, and reduce conflict over treatment choices for persons with advanced dementia. DESIGN Semistructured interview with prestudy and poststudy design for surrogates in the intervention group. SETTING Twenty-four skilled nursing facilities across North Carolina participating in a cluster randomized trial. PARTICIPANTS Two hundred and fifty-five surrogate decision makers for nursing home residents with advanced dementia and feeding problems, in control (n = 129) and intervention (n = 126) groups. INTERVENTION For intervention surrogates only, an audiovisual-print decision aid provided information on dementia, feeding problems in dementia, advantages and disadvantages of feeding tubes or assisted oral feeding options, and the role of surrogates in making these decisions. MEASUREMENTS The interview included open-ended items asking surrogates to report advantages and disadvantages of tube feeding and assisted oral feeding. Knowledge of feeding options was measured with 19 true/false items and items measuring expectation of benefit from tube feeding. Surrogates reported which of these two feeding options they preferred for the person with dementia, and how confident they were in this choice; their level of conflict about the choice was measured using the decisional conflict scale. RESULTS Before the decision aid, surrogates described advantages and disadvantages of assisted oral feeding and tube feeding in practical, ethical, and medical terms. After review of the decision aid, intervention surrogates had improved knowledge scores (15.5 vs 16.8; P < .001), decreased expectation of benefits from tube feeding (2.73 vs 2.32; P = .001), and reduced decisional conflict (2.24 vs 1.91; P < .001). Surrogates preferred assisted oral feeding initially and reported more certainty about this choice after the decision aid. CONCLUSIONS A structured decision aid can be used to improve decision making about feeding options in dementia care.
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Affiliation(s)
- E Amanda Snyder
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina, Chapel Hill, NC 27759, USA
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Cohen LW, Steen JT, Reed D, Hodgkinson JC, Soest-Poortvliet MC, Sloane PD, Zimmerman S. Family Perceptions of End-of-Life Care for Long-Term Care Residents with Dementia: Differences Between the United States and the Netherlands. J Am Geriatr Soc 2012; 60:316-22. [DOI: 10.1111/j.1532-5415.2011.03816.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren W. Cohen
- Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill; North Carolina
| | | | - David Reed
- Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill; North Carolina
| | - Jennifer C. Hodgkinson
- Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill; North Carolina
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Zimmerman S, Connolly R, Zlotnik JL, Bern-Klug M, Cohen LW. Psychosocial care in nursing homes in the era of the MDS 3.0: perspectives of the experts. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2012; 55:444-461. [PMID: 22783960 DOI: 10.1080/01634372.2012.667525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Meeting psychosocial needs of nursing home residents is increasingly regarded as a critical component of care, and the nationally-mandated nursing home care screening instrument- the Minimum Data Set (MDS) 3.0-was modified and implemented in 2010 to promote better assessment of psychosocial needs and health. Recognizing the importance of psychosocial well-being among nursing home residents, and the promise of MDS 3.0 for improving psychosocial care, this article reports recommendations derived from a conference of stakeholders representing diverse disciplines and organizations regarding next steps following MDS 3.0 screening. Results relate to seven areas of psychosocial care and address cross-cutting recommendations to improve psychosocial care.
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Affiliation(s)
- Sheryl Zimmerman
- School of Social Work, University of North Carolina, Chapel Hill, NC, USA.
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van Soest-Poortvliet MC, van der Steen JT, Zimmerman S, Cohen LW, Munn J, Achterberg WP, Ribbe MW, de Vet HCW. Measuring the quality of dying and quality of care when dying in long-term care settings: a qualitative content analysis of available instruments. J Pain Symptom Manage 2011; 42:852-63. [PMID: 21620642 DOI: 10.1016/j.jpainsymman.2011.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 02/11/2011] [Accepted: 02/15/2011] [Indexed: 10/18/2022]
Abstract
CONTEXT Long-term care (LTC) settings have become a significant site for end-of-life care; consequently, instruments that assess the quality of dying and care may be useful in these settings. OBJECTIVES To evaluate the content of available measurement instruments to assess the quality of dying and care when dying. METHODS Qualitative content analysis to categorize items as structure of care, process of care, satisfaction with health care (the first three representing quality of care and its evaluation), quality of dying, or patient factors. RESULTS Instruments that measure mostly quality of care and its evaluation are the Family Perception of Physician-Family Caregiver Communication, End-of-Life in Dementia (EOLD) Satisfaction With Care, Family Perception of Care Scale, Toolkit of Instruments to Measure End-of-Life Care after-death bereaved family member interview (nursing home version), and the Family Assessment of Treatment at the End-of-Life Short version. Instruments measuring quality of dying are the EOLD-Comfort Assessment in Dying, EOLD-Symptom Management, Mini-Suffering State Examination, and Palliative Care Outcome Scale. The Quality of Dying in Long-Term Care measures care and dying. The Minimum Data Set-Palliative Care measures mostly dying and patient factors. The instruments differ in dementia specificity, time of administration, and respondent. CONCLUSION Instruments that assess quality when dying differ in several ways and most do not measure a single construct, which is relevant to guiding and evaluating care. Comparing psychometric properties and usefulness of instruments that measure similar constructs is the next step in determining which are best suited for use in LTC.
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Hanson LC, Carey TS, Caprio AJ, Lee TJ, Ersek M, Garrett J, Jackman A, Gilliam R, Wessell K, Mitchell SL. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc 2011; 59:2009-16. [PMID: 22091750 DOI: 10.1111/j.1532-5415.2011.03629.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To test whether a decision aid improves quality of decision-making about feeding options in advanced dementia. DESIGN Cluster randomized controlled trial. SETTING Twenty-four nursing homes in North Carolina. PARTICIPANTS Residents with advanced dementia and feeding problems and their surrogates. INTERVENTION Intervention surrogates received an audio or print decision aid on feeding options in advanced dementia. Controls received usual care. MEASUREMENTS Primary outcome was the Decisional Conflict Scale (range: 1-5) measured at 3 months; other main outcomes were surrogate knowledge, frequency of communication with providers, and feeding treatment use. RESULTS Two hundred fifty-six residents and surrogate decision-makers were recruited. Residents' average age was 85; 67% were Caucasian, and 79% were women. Surrogates' average age was 59; 67% were Caucasian, and 70% were residents' children. The intervention improved knowledge scores (16.8 vs 15.1, P < .001). After 3 months, intervention surrogates had lower Decisional Conflict Scale scores than controls (1.65 vs 1.90, P < .001) and more often discussed feeding options with a healthcare provider (46% vs 33%, P = .04). Residents in the intervention group were more likely to receive a dysphagia diet (89% vs 76%, P = .04) and showed a trend toward greater staff eating assistance (20% vs 10%, P = .08). Tube feeding was rare in both groups even after 9 months (1 intervention vs 3 control, P = .34). CONCLUSION A decision aid about feeding options in advanced dementia reduced decisional conflict for surrogates and increased their knowledge and communication about feeding options with providers.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Emilsdóttir AL, Gústafsdóttir M. End of life in an Icelandic nursing home: an ethnographic study. Int J Palliat Nurs 2011; 17:405-11. [DOI: 10.12968/ijpn.2011.17.8.405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Miller SC, Lima JC, Mitchell SL. Hospice care for persons with dementia: The growth of access in US nursing homes. Am J Alzheimers Dis Other Demen 2010; 25:666-73. [PMID: 21131673 PMCID: PMC3009455 DOI: 10.1177/1533317510385809] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/RATIONALE Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice. METHODS For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia. RESULTS Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely. CONCLUSIONS Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.
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Affiliation(s)
- Susan C Miller
- Department of Community Health, Brown University, Providence, RI, USA.
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Abstract
Concerns about the quality of long-term care have resulted in an extensive array of regulations governing provider behavior. This article reports the results of a survey of 1,147 long-term care specialists on issues related to the government’s performance in assuring quality and improving care. With the exception of providers, more than half of specialists ranked the quality of the average nursing home as fair or poor; home health agencies and even assisted-living facilities fared only somewhat better. Yet despite the perceived ineffectiveness of the current regime, the majority of specialists expressed a general willingness to continue pursuing more stringent and enhanced enforcement and to proceed down the same path with assisted-living facilities. Furthermore, while most were not sanguine about public reporting, the majority favored pay-for-performance, even though both rely on the same information. In addition to constituency group affiliation, differences in views derived largely from respondents’ ideological predispositions.
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Biola H, Sloane PD, Williams CS, Daaleman TP, Zimmerman S. Preferences versus practice: life-sustaining treatments in last months of life in long-term care. J Am Med Dir Assoc 2010; 11:42-51. [PMID: 20129214 DOI: 10.1016/j.jamda.2009.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/18/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST. DESIGN AND PARTICIPANTS After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility. SETTING The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states. MEASUREMENTS Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that. RESULTS Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034). CONCLUSION Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.
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Affiliation(s)
- Holly Biola
- Geriatrics Division, Department of Medicine, Duke University, Durham, NC, USA.
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