End-of-Life Care and Discussions in Japanese Geriatric Health Service Facilities: A Nationwide Survey of Managing Directors' Viewpoints

BACKGROUND

Geriatric health service facilities (GHSFs) play important roles as intermediate care facilities for elderly individuals temporarily when they need rehabilitation before returning home. However, the number of residents spending their end-of-life (EOL) period in such facilities is increasing. To improve the quality of EOL care, end-of-life discussions (EOLDs) are recommended by some guidelines and studies.

AIM

This study aimed to clarify the current practice of EOL care and EOLDs in GHSFs in Japan.

METHODS

We conducted a nationwide cross-sectional survey by mailing questionnaires about EOL care and EOLDs to 3437 GHSF managing directors. The questionnaire was developed through a literature review and discussion among the researchers and experts. Descriptive statistics summarized the data. We also analyzed the factors related to GHSFs conducting EOLDs using Fisher exact tests.

RESULTS

The response rate was 20.7% (713 of 3437). Among the respondents, 75.2% (536 of 713) of GHSFs provided EOL care and 73.1% (521 of 713) conducted EOLDs. The most common reasons for difficulties in providing EOL care included the lack of EOL education for nurses and care workers, and their fear about caring for dying residents. End-of-life discussions were mostly initiated after the deterioration of a resident's condition and were conducted with families by physicians. Statistically significant factors of GHSFs conducting EOLDs included providing EOL education for nurses and care workers, availability of private room for critically ill residents, emergency on-call doctors, and EOL care.

CONCLUSION

Adequate practical staff education programs for EOL care including EOLDs may be crucial for quality of end-of-life care in aged care facilities.

Pain and hospice care in nursing home residents with dementia and terminal cancer

AIM

One condition associated with severe end-of-life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer.

METHODS

Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out.

RESULTS

A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1-14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1-0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time.

CONCLUSIONS

Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia.

Opinion survey of nursing or caring staff at long-term care facilities about end-of-life care provision and staff education

Although long-term care facilities are expected to assume a growing responsibility in caring for the dying elderly, research in this area is still in its early stages. The present study aims to explore the educational and support needs of nursing home care staff in comparison with geriatric hospital, which provide 24-h physician service. The subjects in this study were caring staff of 45 long-term care facilities in Nagoya City as of December 2006. Data was collected through questionnaires covering the following: (i) possible barriers to end-of-life care provision at own facilities and (ii) areas in which a need for education was perceived. One thousand and fifty nine staff responded. Approximately three-fourths of the staff felt that additional staff, physician or nurse available 24 h, and staff education were crucial in the provision of end-of-life care at their facilities. Dementia care, physical care, communication with residents and families, psychological aspects of dying, and pain/symptom control were listed as the five items deemed most important to address. This study indicated that nursing and caring staff recognize a need in 24-h medical service and hospital involvement of end-of-life care provision at their facilities, and that staff are eager to be educated concerning end-of-life.