Communication with Residents and Families in Nursing Homes at the End of Life

Examining the Relationship Between Rural and Urban Clinicians' Familiarity With Patients and Families and Their Comfort With Palliative and End-of-Life Care Communication

Background: Effective healthcare clinician communication is a key component of quality palliative and end-of-life (PEOL) care. However, communication may be hampered when clinicians are not comfortable initiating these conversations with patients and their families. Clinicians working in rural areas report several barriers to providing palliative care. This study examined the relationship between rural and urban clinicians' reported familiarity with their patients and families end-of-life, their reported comfort in initiating PEOL conversations, and their PEOL care knowledge. Method: This study used a cross-sectional design to examine the relationships between rural and urban clinicians' familiarity, their comfort in PEOL communication, and their PEOL care knowledge. Results: N = 548 rural and urban clinicians participated. Rural clinicians reported greater familiarity, more PEOL knowledge, and more comfort with PEOL communication. Multiple regression analyses of PEOL knowledge showed significant associations in knowledge with older clinicians (P < 0.01) and additional palliative care training (P < 0.01); comfort in PEOL communication had significant associations with more palliative care training (P < 0.01) and opportunities to provide palliative care (P < 0.01). Conclusion: The concept of familiarity is highly complex and poorly understood in relation to PEOL care in both rural and urban settings. Future research is needed to explore how additional training in PEOL care and clinician reported familiarity positively impact patient outcomes by increasing the number of advance directives completed and followed and improved documentation of advance care planning.

Timing of Goals of Care Discussions in Nursing Homes: A Systematic Review

OBJECTIVES

Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Adult populations in NH settings.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs.

CONCLUSIONS AND IMPLICATIONS

The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population.

Inadequate human resources, equipment and training: A qualitative assessment of the objectives of the NUHELP end-of-life care programme in the context of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic had a particularly severe impact on nursing homes, exposing numerous pre-existing deficiencies in end-of-life care.

AIM

To describe how the COVID-19 pandemic affected nursing home and primary care professionals' attempts to achieve the objectives of a pre-existing end-of-life programme and to explore their personal experiences of end-of-life care in these facilities.

DESIGN

A qualitative descriptive study using thematic analysis.

SETTING/PARTICIPANTS

Twenty semi-structured interviews were conducted from March to November 2020 with professionals from nursing homes and primary care facilities who participated in the development of the NUHELP programme.

RESULTS

Six main themes were identified: (1) Comprehensive assessments of residents at the homes were not conducted due to excessive workload and high staff turnover. (2) New technologies and changes to professional roles were used to meet relatives' needs for information. Residents only received information when they requested it. (3) Advance care planning was not carried out and was limited to potential hospital transfer. (4) Arrangements were made to allow relatives to spend time with residents during their final moments, but complicated grief among relatives and professionals is anticipated. (5) Management of complexity varied depending on the degree of coordination with primary care facilities. (6) Nursing home professionals felt abandoned, with a lack of human resources, equipment and training.

CONCLUSIONS

The pandemic cast light on existing shortcomings in nursing homes in terms of comprehensive assessments, communication, decision making, grief management and palliative care complexity. Nursing homes need more human, material and training resources, as well as improved coordination with the public healthcare system.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home

BACKGROUND

Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care.

AIMS

To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication.

METHOD

This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed.

FINDINGS

Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory.

CONCLUSION

Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

Communicating With Nursing Home Residents About End of Life

Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.

Differences in advance care planning among nursing home care staff

BACKGROUND

A team-based approach has been advocated for advance care planning in nursing homes. While nurses are often put forward to take the lead, it is not clear to what extent other professions could be involved as well.

OBJECTIVES

To examine to what extent engagement in advance care planning practices (e.g. conversations, advance directives), knowledge and self-efficacy differ between nurses, care assistants and allied care staff in nursing homes.

DESIGN

Survey study.

PARTICIPANTS/SETTING

The study involved a purposive sample of 14 nursing homes in Flanders, Belgium. Nurses, care assistants and allied care staff (e.g. social workers, physical therapists) completed a survey.

ETHICAL CONSIDERATIONS

The study was approved by the University Hospital of Brussels (B.U.N. 143201834759), as part of a cluster randomized controlled trial (clinicaltrials.gov NCT03521206).

RESULTS

One hundred ninety-six nurses, 319 care assistants and 169 allied staff participated (67% response rate). After adjusting for confounders, nurses were significantly more likely than care assistants to have carried out advance care planning conversations (odds ratio 4; 95% confidence interval 1.73-9.82; p < 0.001) and documented advance care planning (odds ratio 2.67; 95% confidence interval 1.29-5.56; p < 0.001); differences not found between allied staff and care assistants. Advance care planning knowledge total scores differed significantly, with nurses (estimated mean difference 0.13 (score range 0-1); 95% confidence interval 0.08-0.17; p < 0.001) and allied staff (estimated mean difference 0.07; 95% confidence interval 0.03-0.12; p < 0.001) scoring higher than care assistants. We found no significant differences regarding self-efficacy.

DISCUSSION

While nursing home nurses conducted more advance care planning conversations and documentation than allied care staff and care assistants, these two professional groups may be a valuable support to nurses in conducting advance care planning, if provided with additional training.

CONCLUSIONS

Allied care staff and care assistants, if trained appropriately, can be involved more strongly in advance care planning to enhance relational and individual autonomy of nursing home residents, alongside nurses. Future research to improve and implement advance care planning should consider this finding at the intervention development stage.

The last week of life of nursing home residents with advanced dementia: a retrospective study

BACKGROUND

Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region.

METHODS

This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death.

RESULTS

Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death.

CONCLUSIONS

Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

Factors Associated with Perception of the Quality of Physicians' End-of-life Communication in Long-Term Care Facilities: PACE Cross-Sectional Study

OBJECTIVE

To examine factors associated with perceived quality of communication with physicians by relatives of dying residents of long-term care facilities (LTCFs).

DESIGN

A cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. In each LTCF, deaths of residents during the 3 months before the researcher's visit were reported. Structured questionnaires were sent to the identified relatives of deceased residents.

SETTINGS AND PARTICIPANTS

A total of 736 relatives of deceased residents in 210 LTCFs (in Belgium, Finland, Italy, the Netherlands, and Poland).

METHODS

The Family Perception of Physician-Family Communication scale (FPPFC) was used to assess the quality of end-of-life (EOL) communication with physicians as perceived by relatives. We applied multilevel linear regression models to find factors associated with the FPPFC score.

RESULTS

The quality of EOL communication with physicians was perceived by relatives as higher when the relative spent more than 14 hours with the resident in the last week of the resident's life (b = 0.205; P = .044), and when the treating physician visited the resident at least 3 times in the last week of the resident's life (b = 0.286; P = .002) or provided the resident with palliative care (b = 0.223; P = .003). Relatives with higher emotional burden perceived the quality of EOL communication with physicians as lower (b = -0.060; P < .001). These results had been adjusted to countries and LTCF types with physicians employed on-site or off-site of the facility.

CONCLUSION

The quality of EOL communication with physicians, as perceived by relatives of dying LTCF residents, is associated with the number of physician visits and amount of time spent by the relative with the resident in the last week of the resident's life, and relatives' emotional burden.

IMPLICATIONS

LTCF managers should organize care for dying residents in a way that enables frequent interactions between physicians and relatives, and emotional support to relatives to improve their satisfaction with EOL communication.

Hospice care education needs of nursing home staff in South Korea: a cross-sectional study

Background

While the importance of hospice care education in nursing homes is recognized, the volume of research on the specific educational needs of caregivers in hospice care in nursing homes is still lacking. This study aimed to assess educational needs in hospice care among the nursing home staff in South Korea, and to examine factors related to their education needs.

Methods

This is a cross-sectional descriptive study. A total of 324 nursing staff members recruited from 15 nursing homes in South Korea participated in this cross-sectional study. Measurements included demographic information, organizational characteristics, education experiences in hospice care, and educational needs in hospice care based on questionnaires developed by Whittaker and colleagues. Data were analyzed using descriptive statistics, t-test, ANOVA, and multiple regression techniques.

Results

In the present study, 70.6% (n = 218) of respondents reported that they had previous experience with education in hospice care and expressed their continued need for further education. The provision of care in the last days of a patient’s life was the most frequent issue identified by nursing home staff for further education. Factors predicting educational needs in hospice care included provision of hospice care services in nursing homes and the existence of hospice care team meetings in the institution. Multiple regression analysis resulted in 14.3% of explained variance in the educational needs of nursing home staff in hospice care.

Conclusions

Nursing home staff members showed high levels of need for training in hospice care. Therefore, it is imperative for nursing home administrators to initiate and support well-suited hospice care education for multi-level care workers on an ongoing basis.

Care staff's self-efficacy regarding end-of-life communication in the long-term care setting: Results of the PACE cross-sectional study in six European countries

BACKGROUND

An important part of palliative care is discussing preferences at end of life, however such conversations may not often occur. Care staff with greater self-efficacy towards end-of-life communication are probably more likely to have such discussions, however, there is a lack of research on self-efficacy towards end-of-life discussions among long-term care staff in Europe and related factors.

OBJECTIVES

Firstly, to describe and compare the self-efficacy level of long-term care staff regarding end-of-life communication across six countries; secondly, to analyse characteristics of staff and facilities which are associated to self-efficacy towards end-of-life communication.

DESIGN

Cross-sectional survey.

SETTINGS

Long-term care facilities in Belgium, England, Finland, Italy, the Netherlands and Poland (n = 290).

PARTICIPANTS

Nurses and care assistants (n = 1680) completed a self-efficacy scale and were included in the analyses.

METHODS

Care staff rated their self-efficacy (confidence in their own ability) on a scale of 0 (cannot do at all) to 7 -(certain can do) of the 8-item communication subscale of the Self-efficacy in End-of-Life Care survey. Staff characteristics included age, gender, professional role, education level, training in palliative care and years working in direct care. Facility characteristics included facility type and availability of palliative care guidelines, palliative care team and palliative care advice. Analyses were conducted using Generalized Estimating Equations, to account for clustering of data at facility level.

RESULTS

Thde proportion of staff with a mean self-efficacy score >5 was highest in the Netherlands (76.4%), ranged between 55.9% and 60.0% in Belgium, Poland, England and Finland and was lowest in Italy (29.6%). Higher levels of self-efficacy (>5) were associated with: staff over 50 years of age (OR 1.86 95% CI[1.30-2.65]); nurses (compared to care assistants) (1.75 [1.20-2.54]); completion of higher secondary or tertiary education (respectively 2.22 [1.53-3.21] and 3.11 [2.05-4.71]; formal palliative care training (1.71 [1.32-2.21]); working in direct care for over 10 years (1.53 [1.14-2.05]); working in a facility with care provided by onsite nurses and care assistants and offsite physicians (1.86 [1.30-2.65]); and working in a facility where guidelines for palliative care were available (1.39 [1.03-1.88]).

CONCLUSION

Self-efficacy towards end-of-life communication was most often low in Italy and most often high in the Netherlands. In all countries, low self-efficacy was found relatively often for discussion of prognosis. Palliative care education and guidelines for palliative care could improve the self-efficacy of care staff.

Condition-Specific Pamphlets to Improve End-of-life Communication in Long-term Care: Staff Perceptions on Usability and Use

OBJECTIVES

This article reports findings on the usability and staff use of 5 condition- specific pamphlets of high prevalence in long-term care (LTC): dementia, heart failure, chronic obstructive pulmonary disease, renal failure, and frailty. The pamphlets were created in response to residents', families', and staff's recommendations for activating early reflections and communication about end-of-life care.

DESIGN

A mixed-method (qualitative and quantitative) survey design was used. Step 1 collected survey data on the usability of the pamphlets. Step 2 collected survey data on pamphlet use.

SETTINGS AND PARTICIPANTS

Two nurses with specialized palliative care training, 2 resident/family representatives, 10 condition-specific specialists, and 33 LTC palliative leads reviewed the pamphlets for usability prior to distribution. A total of 178 LTC home staff in 4 participating LTC homes reported on pamphlet use.

MEASURES

Specialists and resident/family representatives were asked to provide open comments and LTC home palliative leads were asked to complete a survey on the accuracy, readability, and relevance of the pamphlets. After 6 months of distribution, all staff in participating LTC homes were asked to complete a survey on pamphlet use, usefulness, and comfort with distribution.

RESULTS

The pamphlets were reportedly accurate, relevant, and easy to understand. Following 6 months of availability, most staff in LTC had read the pamphlets, found the information useful, and planned to share them. However, half of the staff questioned their role in pamphlet distribution and most had not distributed them. Regulated staff (ie, staff affiliated with a regulated profession) expressed more comfort sharing the pamphlets than care aides and support staff.

CONCLUSIONS/IMPLICATIONS

Condition-specific pamphlets appear to hold promise in providing residents and families with relevant information that may activate early reflections and conversations about end-of-life care. However, structured implementation strategies, training, and discussions are required to improve staff comfort with distribution and explore roles in distribution and follow-up.

Transforming End-of-Life Care by Implementing a Patient-Centered Care Model: Findings From an Action Research Project

Patient-centered care is valued by health care professionals working in palliative care settings. However, studies have revealed the difficulty of adopting patient-centered care in daily practice and of sharing its meaning within the interdisciplinary team. The aim of this study was to report the process of transforming end-of-life care by implementing a patient-centered model of care in an Italian hospice. An action research process was conducted between June 2012 and June 2014. The following phases were performed: (a) "looking" phase: the diagnosis was established by collecting data through semistructured interviews in the field study and through the administration of the Frommelt Attitude Toward the Care of the Dying Scale Form B-Italian Version; (b) "thinking" phase: staff members, guided by a research team, redesigned practice by identifying priorities in improvements and actions through multiprofessional focus groups; (c) "acting" phase: actions identified in the previous phase were implemented; and (d) "relooking" phase: the same data collection processes used in the looking phase were applied to evaluate the outcomes achieved. Three areas of improvement have been established: (1) symptoms were intensively audited through patient self-reports by using validated tools; (2) patients' family needs were also regularly collected, documented in clinical records, and addressed; (3) patients' family members were involved in the plan of care through support and education. Inpatient hospice health carers in this study were aware of the concept of patient-centered care. However, its actual implementation was lacking. An action research approach helped them to implement expected changes.

Palliative care culture in nursing homes: the relatives' perspective

Background

Nursing homes are confronted with a significant change in their client structure. Palliative care gains importance in caring for residents until the end of their life. Relatives play a crucial role in caring for older people in nursing homes, especially in palliative care. As the perspective of relatives on palliative care culture in nursing homes has not yet been studied extensively, research in this field still has an exploratory character.

Aim

The aim of the paper is to highlight some of the most important insights into themes and issues that relatives of persons having died in a nursing home find essential, with a view to fostering a well-established palliative care culture.

Methods

Within a qualitative approach, four focus group interviews were conducted.

Findings

Findings indicate that good communication is a core element of a well-established palliative care culture. Direct contact with relatives, talking about death and dying and the opportunity to be involved in decision-making all support a good palliative care culture. The fact that residents have a diverse range of social backgrounds, for example, regarding ethnicity, gender and living with dementia, influences palliative care in nursing homes and has to be taken into account.

Conclusions

To create a good palliative care culture, management has to support this approach, continuously develop appropriate structures and act in a competent way.

Family care conferences in long-term care: Exploring content and processes in end-of-life communication

ABSTRACTObjective:End-of-life (EoL) communication in long-term care (LTC) homes is often inadequate and delayed, leaving residents dying with unknown preferences or goals of care. Poor communication with staff contributes to families feeling unprepared, distressed, and dissatisfied with care. Family care conferences (FCCs) aim to increase structured systematic communication around goals and plans for the end of life. As part of the Strengthening a Palliative Approach to Care (SPA-LTC) project, FCCs were implemented in four LTC sites in Ontario, Canada. The purpose of this substudy was to examine FCC content and such guiding processes as documentation and multidisciplinary staff participation.

METHOD

A total of 24 FCCs were held for residents with a Palliative Performance Scale score of 40% (nearing death). Data were collected from conference forms (i.e., Family Questionnaires, Care Plan Conference Summaries), site-specific electronic chart documents, and fieldnotes. Directed content analysis of data was informed by the Canadian Hospice Palliative Care Association's Square of Care Model, which describes eight domains of care: disease management, physical, psychological, social, practical, spiritual, EoL, and loss/bereavement.

RESULTS

The FCCs addressed an average of 71% of the content domains, with physical and EoL care addressed most frequently and loss/bereavement addressed the least. Two goals and five interventions were documented and planned on average per FCC. Examination of the processes supporting EoL communication found: (1) advantages to using FCC forms versus electronic charts; and (2) high levels of multidisciplinary participation overall but limited participation of personal support workers (PSWs) and physicians.

SIGNIFICANCE OF RESULTS

Communication around the end of life in LTC can be supported through the use of FCCs. Description of content and FCC processes provides guidance to persons implementing FCCs. Recommendations for tailoring conferences to optimize communication include use of specific conference forms, increased bereavement discussion, and further engagement of PSWs and physicians.

Broadening End-of-Life Comfort to Improve Palliative Care Practices in Long Term Care

This study aimed to (1) explore how palliative care in long-term care (LTC) addresses the tensions associated with caring for the living and dying within one care community, and (2) to inform how palliative care practices may be improved to better address the needs of all residents living and dying in LTC as well as those of the families and support staff. This article reports findings from 19 focus groups and 117 participants. Study findings reveal that LTC home staff, resident, and family perspectives of end-of-life comfort applied to those who were actively dying and to their families. Our findings further suggest that eliciting residents' perceptions of end-of-life comfort, sharing information about a fellow resident's death more personally, and ensuring that residents, families, and staff can constructively participate in providing comfort care to dying residents could extend the purview of end-of-life comfort and support expanded integration of palliative principles within LTC.