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de Sola-Smith K, Gilissen J, van der Steen JT, Mayan I, Van den Block L, Ritchie CS, Hunt LJ. Palliative Care in Early Dementia. J Pain Symptom Manage 2024:S0885-3924(24)00798-X. [PMID: 38848792 DOI: 10.1016/j.jpainsymman.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/14/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Palliative care is recommended for all people with dementia from diagnosis through end-of-life. However, palliative care needs and effective elements of palliative care are not well-defined for the earlier stages of dementia. OBJECTIVE To systematically map current research on palliative care early in the disease trajectory of dementia. DESIGN Scoping review of scientific literature. DATA SOURCES PubMed, CINAHL, EMBASE, Cochrane, PsycINFO, Web of Science. REVIEW METHODS We included studies published in English over the last decade (through March 2022) that focused on palliative care in early stages of dementia and targeted outcomes in palliative care domains. Two authors independently screened abstracts and full texts and scored the quality of included studies using tools by the Joanna Briggs Institute. RESULTS Among the 77 papers reviewed, few addressed early stages of dementia specifically. We found that: 1) While "early" palliative care was not well-defined in the literature, evidence indicated that palliative care needs were present at or before diagnosis and across the trajectory. Notable opportunities for palliative care arise at 'tipping points' (i.e., when symptoms, functional status, or caregiving needs change). 2) Palliative care needs in early dementia include advocacy for goal-aligned care in the future, reassurance against the threat of negligence and abandonment by caregivers, planning for future scenarios of care (practical, individual, and relational needs), and establishing of long-term relationships with providers entrusted for care later in disease. 3) Elements of effective palliative care in early dementia could include dementia-specific ACP and goals of care discussions, navigation for building a network of support, provision of tools and resources for family, tailored care and knowledge of the person, and well-prepared dementia-care providers. The scarcity of palliative care studies aimed at early disease indicates a gap in the evidence in dementia care. CONCLUSION The literature on palliative care in early dementia is sparse. Future studies should focus on assessment tools for optimizing timing of palliative care in early dementia, gaining better understanding of patient and family needs during early phases of disease, and providing training for providers and families in long-term relationships and communication around goals of care and future planning.
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Affiliation(s)
- Karen de Sola-Smith
- Department of Geriatrics (K.d.S.), Palliative and Extended Care, Veterans Affairs Medical Center, San Francisco, California, USA; Department of Physiological Nursing (K.d.S., L.J.H.), University of California San Francisco, California, USA.
| | - Joni Gilissen
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Department of Family Medicine and Chronic Care (J.G., L.V.B), Vrije Universiteit Brussel (VUB) and Department of Public Health and Primary Care, End-of-Life Care Research Group, Universiteit Gent, Brussels, Belgium
| | - Jenny T van der Steen
- Department of Primary and Community Care and Radboudumc Alzheimer Center (J.T.S.), Radboud university medical center, Nijmegen, The Netherlands; Department of Public Health and Primary Care (J.T.S.), Leiden University Medical Center, Leiden, The Netherlands
| | - Inbal Mayan
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care (J.G., L.V.B), Vrije Universiteit Brussel (VUB) and Department of Public Health and Primary Care, End-of-Life Care Research Group, Universiteit Gent, Brussels, Belgium
| | - Christine S Ritchie
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Division of Palliative Care and Geriatric Medicine and the Mongan Institute for Aging and Serious Illness (CASI) (C.S.R.), Massachusetts General Hospital (MGH), Boston, Massachusetts, USA; Harvard Medical School (C.S.R.), Harvard University, Boston, Massachusetts, USA
| | - Lauren J Hunt
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Department of Physiological Nursing (K.d.S., L.J.H.), University of California San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies (L.J.H.), University of California San Francisco, California, USA
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Auclair I, Bourbonnais A. The Involvement of Caregivers in the End-of-life Care of an Older Adult Living in a Long-term Care Home: A Qualitative Case Study with Nurses and Relatives. Can J Nurs Res 2024:8445621241247862. [PMID: 38619920 DOI: 10.1177/08445621241247862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND A key role of nurses working in long-term care homes (LTCHs) is to promote the involvement of care partners in end-of-life (EOL) care. However, studies on the involvement of care partners in EOL care in LTCHs have focused on care planning and decision-making. While care partners can participate in other ways, it's unclear how they are currently involved in EOL care by staff. PURPOSE We aimed to explore the involvement of care partners in the EOL care of an older adult living in a LTCH. METHODS A qualitative case study was conducted. Data was collected from a sample of four nurses and three care partners, using sociodemographic questionnaires, individual semi-structured interviews, documents pertaining to the LTCH's philosophy for EOL care, and a field diary. RESULTS The results of a thematic analysis showed the broad scope of care partners' possible involvement, including contributing to care, obtaining information, and being present. As there was some variation in care partners' desire to be involved, nurses seemed to rely on them to convey their wishes. To promote this involvement, some strategies aimed at health professionals and managers were suggested. CONCLUSIONS These results can guide improvement in clinical practices and raise awareness on the EOL care experiences of care partners.
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Affiliation(s)
- Isabelle Auclair
- PhD candidate, Faculty of Nursing, Université de Montréal, Montreal, Canada
- Research assistant, Research Centre of the Institut universitaire de gériatrie de Montréal, Montreal, Canda
| | - Anne Bourbonnais
- Full professor, Faculty of Nursing, Université de Montréal, Montreal, Canada
- Researcher, Research Centre of the Institut universitaire de gériatrie de Montréal, Montreal, Canada
- Chairholder of the Canada Research Chair in Care for Older People Chairholder of the Research Chair in Nursing Care for Older People and their Families, Montreal, Canada
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Lynch B, Ryan AA, O’Neill M, Penney S. The factors that influence care home residents’ and families’ engagement with decision-making about their care and support: an integrative review of the literature. BMC Geriatr 2022; 22:873. [PMID: 36396991 PMCID: PMC9672635 DOI: 10.1186/s12877-022-03503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background: As care homes play an important role in the lives of an increasing number of older people, it is pivotal to understand how residents’ and their families engage in decision-making about their care and support. Internationally, there is an increasing emphasis in long-term care settings on the right of residents to be actively involved in all aspects of decision-making about their care and support. However, the steps necessary to achieving a culture of shared decision-making in long-term care settings remain unclear. The aim of this literature review is to summarise what is known in the literature about the factors that influence care home residents’ and families’ engagement with decision-making about their care and support. Methods: An integrative literature reviews was carried out, guided by the methodological framework proposed by Whittemore and Knafl (2005). CINAHL, Medline Ovid and ProQuest Health and Medical databases were searched for relevant articles from 2011 to 2021. A three-step method was used, including the use of reference and citation management software to manage search results and identify duplicate citations. Abstracts and full texts were reviewed by two reviewers. Details of the selected articles were then extracted using the Data Extraction Form. Results: In total, 913 articles were located and 22 studies were included in the final analysis. The thematic analysis identified three main themes that illustrate the complexities of shared decision-making in care homes: (a) a positive culture of collaborative and reciprocal relationships; (b) a willingness to engage and a willingness to become engaged; and (c) communicating with intent to share and support rather than inform and direct. Conclusion: The implementation of shared decision-making in care homes is highly dependent on the support and nurturing of collaborative and reciprocal relationships between residents, families, and staff. Part of this process includes ascertaining the willingness of residents and families to become engaged in shared decision-making. Communication skills training for staff and guided approaches that view decision-making as a supportive process rather than a once off event are essential prerequisites for implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03503-8.
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Muthui R, Paun O. Process of Advance Care Planning in Nursing Home Settings: An Integrative Literature Review. Res Gerontol Nurs 2022; 15:312-320. [PMID: 36214735 DOI: 10.3928/19404921-20220930-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Advance care planning (ACP) allows individuals to communicate their wishes for future medical care. ACP is particularly important among those diagnosed with Alzheimer's disease and related dementias (ADRD) due to decline in cognition. In the nursing home setting, conducting ACP with residents with ADRD and their family caregivers is challenging. The purpose of the current integrative review was to: (a) examine the evidence on the process of conducting ACP with residents with ADRD and their family caregivers in nursing home settings, and (b) understand who conducts ACP and when and how ACP is being conducted with residents with ADRD and their family caregivers. Gaps were identified, such as lack of a systematic approach to addressing ACP in nursing homes, lack of clear roles in conducting ACP, family caregivers' and nursing home staff's lack of knowledge and skills to engage in ACP, and lack of diversity in study samples. To improve clinical practice, future studies should explore standardization of the ACP process in the nursing home setting. [Research in Gerontological Nursing, xx(x), xx-xx.].
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Visser M, Smaling HJA, Parker D, van der Steen JT. How Do We Talk With People Living With Dementia About Future Care: A Scoping Review. Front Psychol 2022; 13:849100. [PMID: 35496203 PMCID: PMC9039178 DOI: 10.3389/fpsyg.2022.849100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
A diagnosis of dementia often comes with difficulties in understanding a conversational context and expressing how one feels. So far, research on how to facilitate advance care planning (ACP) for people with dementia focused on defining relevant themes and topics for conversations, or on how to formalize decisions made by surrogate decision makers, e.g., family members. The aim of this review is to provide a better scope of the existing research on practical communication aspects related to dementia in ACP conversations. In November 2020, seven databases were searched to select papers for inclusion (Proquest, Medline, Embase, Scopus, Psycinfo, Amed, and Cinahl). This search was updated in December 2021. The search strategy consisted of three tiers (related terms to "dementia," "communication" and "ACP"), intersected by using the Boolean term "AND," and resulted in 787 studies. Two researchers followed explicit criteria for two sequential levels of screening, based on titles and abstracts and full papers. A total of 22 studies were included for data analysis. Seven topics (i.e., importance of having ACP conversations, knowledge gap, inclusion of people with dementia in ACP conversations, policy vs. practice, adapting to cognitive changes, adapting to psychosocial changes, and adapting to emotional changes) emerged clustered around two themes (i.e., communicating with people with dementia in ACP, and changes in communication due to dementia). This scoping review provides practical suggestions for healthcare professionals to improve ACP communication and uncovered gaps in research on communication aspects related to dementia in ACP conversations, such as non-verbal behavior, timing and implementation, and personal preferences.
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Affiliation(s)
- Mandy Visser
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Hanneke J A Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands.,University Network for the Care Sector Zuid-Holland, Leiden University Medical Center, Leiden, Netherlands
| | - Deborah Parker
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
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Johansson T, Tishelman C, Eriksson LE, Cohen J, Goliath I. Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences. BMC Geriatr 2022; 22:274. [PMID: 35366816 PMCID: PMC8976536 DOI: 10.1186/s12877-022-02915-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.
Methods
This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.
Results
Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.
Conclusions
This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.
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Francisco MC, Lane H, Luckett T, Disalvo D, Pond D, Mitchell G, Chenoweth L, Phillips J, Beattie E, Luscombe G, Goodall S, Agar M. Facilitated case conferences on end-of-life care for persons with advanced dementia-a qualitative study of interactions between long-term care clinicians and family members. Age Ageing 2022; 51:6527373. [PMID: 35150583 DOI: 10.1093/ageing/afab270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prognostic uncertainty and the need for proxy decision-making owing to cognitive impairment in advanced dementia, adds complexity to end-of-life care planning within the long-term care setting. Case conferences provide a structure to facilitate difficult conversations and an opportunity for family and clinicians to engage in prospective planning, and reach agreement on goals of end-of-life care. OBJECTIVE To explore interactions between multidisciplinary healthcare clinicians and families during facilitated case conferences on end-of-life care for residents with advanced dementia. METHODS A qualitative approach was used. Transcripts of audio-recorded case conferences facilitated by a trained registered nurse were coded by two independent researchers and analysed inductively. Transcripts were selected from an available pool until thematic saturation was reached. Emerging themes were confirmed with the wider research group. RESULTS Thematic saturation was reached after 25 transcripts. An overarching theme concerned the ways in which clinicians and families bridged medical and person-centred perspectives. Subthemes included: details of day-to-day care versus establishing overall goals of care; expression of emotion versus retreat from emotion; and missed opportunities versus expressed cues. Successful facilitation served to 'bridge the gap' between family and clinicians. CONCLUSION Facilitation of case conferences for residents with advanced dementia should focus on ensuring that: clinicians do not miss opportunities to discuss end-of-life care; discussions on the minutiae of care regularly return to the resident's broader goals of care; and information on dementia and treatments provided by clinicians is integrated with advice by family members regarding the resident's premorbid values and likely preferences.
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Affiliation(s)
| | - Heather Lane
- Department of Geriatric Medicine, Rockingham General Hospital, Cooloongup, WA, Australia
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Domenica Disalvo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Dimity Pond
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia
| | | | - Lynette Chenoweth
- Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Sydney, Australia
| | - Jane Phillips
- School of Nursing, Faculty of Health, Queensland University of Technology, Sydney, Australia
| | - Elizabeth Beattie
- School of Nursing, Faculty of Health, Queensland University of Technology, Sydney, Australia
| | - Georgina Luscombe
- School of Rural Health (Dubbo/Orange), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
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Hayward JK, Gould C, Palluotto E, Kitson E, Fisher ER, Spector A. Interventions promoting family involvement with care homes following placement of a relative with dementia: A systematic review. DEMENTIA 2021; 21:618-647. [PMID: 34894796 PMCID: PMC8811321 DOI: 10.1177/14713012211046595] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is a wealth of literature investigating the role of family involvement within care homes following placement of a relative with dementia. This review summarises how family involvement is measured and aims to address two questions: (1) which interventions concerning family involvement have been evaluated? And (2) does family involvement within care homes have a positive effect on a resident’s quality of life and behavioural and psychological symptoms of dementia? After searching and screening on the three major databases PsycINFO, MEDLINE and CINAHL Plus for papers published between January 2005 and May 2021, 22 papers were included for synthesis and appraisal due to their relevance to family involvement interventions and or family involvement with resident outcomes. Results show that in 11 interventions designed to enhance at least one type of family involvement, most found positive changes in communication and family–staff relationships. Improvement in resident behavioural and psychological symptoms of dementia was reported in two randomised controlled trials promoting partnership. Visit frequency was associated with a reduction of behavioural and psychological symptoms of dementia for residents with moderate dementia. Family involvement was related to positive quality of life benefits for residents. Contrasting results and methodological weaknesses in some studies made definitive conclusions difficult. Few interventions to specifically promote family involvement within care homes following placement of a relative with dementia have been evaluated. Many proposals for further research made over a decade ago by Gaugler (2005) have yet to be extensively pursued. Uncertainty remains about how best to facilitate an optimum level and type of family involvement to ensure significant quality of life and behavioural and psychological symptoms of dementia benefits for residents with dementia.
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Affiliation(s)
- Janine K Hayward
- Research Department of Clinical, Educational and Health Psychology, 4919University College London, London, UK
| | - Charlotte Gould
- Department of Psychology, 3162Royal Holloway, University of London, Egham, UK
| | - Emma Palluotto
- Department of Clinical Psychology, 4917University of East London, London, UK
| | - Emily Kitson
- Department of People and Organisations, 411270Surrey Business School, University of Surrey, Guildford, UK
| | - Emily R Fisher
- Research Department of Clinical, Educational and Health Psychology, 4919University College London, London, UK
| | - Aimee Spector
- Research Department of Clinical, Educational and Health Psychology, 4919University College London, London, UK
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Hewison A, Hodges E, Balasubramanian S, Swani T. System transformation in palliative and end of life care: developing a model for excellence. J Health Organ Manag 2021; ahead-of-print. [PMID: 34142520 DOI: 10.1108/jhom-06-2020-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study is to report how the palliative and end of life care community in one region of England worked together to create a new model for integrated palliative and end of life care to respond to the challenges of changing demography, the need to reduce unnecessary hospital admissions of people nearing the end of life and to improve the quality of provision in line with current policy. DESIGN/METHODOLOGY/APPROACH A co-production approach to system transformation was adopted involving 73 members of the palliative and end of life care community in one region of England. FINDINGS A new model for the delivery of integrated palliative and end of life care services was produced. The breadth of membership of the co-production working party and constructive/collaborative working helped ensure a viable model was produced. PRACTICAL IMPLICATIONS Although systems' thinking perspectives can help address the challenges of large-scale transformation because they focus on promoting the value of relationships, recognise the nuances of context and the need to understand system behaviour over time, the potential for systems to benefit from this approach is limited by the complexity of the processes involved and the sheer number of issues to be addressed in practical terms by policy makers and change leaders. ORIGINALITY/VALUE The paper explores the contribution that theories of large-scale transformation can make to the design of palliative and end of life care services in health and social care.
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Affiliation(s)
| | | | | | - Tina Swani
- Birmingham St Mary's Hospice, Birmingham, UK
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Affiliation(s)
- Roberta Heale
- School of Nursing, Laurentian University, Sudbury, Ontario, Canada
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Kolanowski A, Behrens L, Lehman E, Oravecz Z, Resnick B, Boltz M, Van Haitsma K, Galik E, Ellis J, Eshraghi K. Living Well With Dementia: Factors Associated With Nursing Home Residents' Affect Balance. Res Gerontol Nurs 2020; 13:21-30. [PMID: 31454406 PMCID: PMC6980972 DOI: 10.3928/19404921-20190823-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/29/2019] [Indexed: 11/20/2022]
Abstract
Well-being is an important outcome for people with dementia. The current study is a secondary analysis of baseline data from an ongoing pragmatic trial. Affect balance, the ratio of positive to negative affect, was used as a measure of well-being, and factors related to it were examined in a sample of 325 nursing home residents. Measures of staff interaction during caregiving, staff knowledge of person-centered approaches for dementia care, staff hours of care, the physical environment, person-centered policies, resident function, and quality of life were obtained using direct observation, staff interview, and medical chart review. The results of the quantile multivariable regression analysis indicated that positive staff interaction and higher resident function were significantly associated with higher affect balance after controlling for other variables. The findings have heuristic value for the development of conceptual frameworks that focus on meaningful outcomes for residents with dementia and future research. [Research in Gerontological Nursing, 13(1), 21-30.].
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Quality Clinical Care in Nursing Facilities. J Am Med Dir Assoc 2019; 19:833-839. [PMID: 30268289 DOI: 10.1016/j.jamda.2018.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/22/2018] [Accepted: 08/24/2018] [Indexed: 01/29/2023]
Abstract
Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.
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Ottoboni G, Chattat R, Camedda C, Galletti M, Macripò S, Mariani E, Ingravallo F. Nursing home staff members' knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes. Aging Clin Exp Res 2019; 31:1675-1683. [PMID: 30637596 DOI: 10.1007/s40520-018-01110-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries. AIMS To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy. METHODS Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants' characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents. RESULTS Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals' knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators. DISCUSSION Nursing home staff members' concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it. CONCLUSIONS A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.
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Economos G, Tholly F, Rhondali W, Ruer M, Tricou C, Fawoubo A, Perceau-Chambard É, Filbet M. Nursing home hospital transfers in the terminally ill: night shift nurses matter! BMJ Support Palliat Care 2019; 10:228-233. [PMID: 31530555 DOI: 10.1136/bmjspcare-2019-001832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 09/04/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND French demographic projection expects an increasing number of older, dependent patients in the next few years. A large proportion of this population lives in nursing homes and their transfer to hospitals at the end of life is an ongoing issue. OBJECTIVE This study explored the factors influencing the transfer of patients living in nursing homes to hospital at the end of life. DESIGN We used a mixed-methods questionnaire developed by an expert group and assessing different characteristics of the nursing homes. PARTICIPANTS All the nursing homes in the Rhône-Alpes area (n=680) were surveyed. RESULTS We obtained 466 (68%) answers. We found that a palliative care programme was present in 336 (72%) nursing homes. The majority had a coordinating physician 428 (82%) and a mean number of 6 nurses for 83 beds, with 83 (18%) having a night shift nurse. There was a mean number of 19 deaths per nursing home during the recorded year. The main cause of death was dementia (41%), cancer-related death (13%). Death occurred mostly in the nursing home (14 74%). Night shift nurse attendance was significantly associated with the place of death: 27 deaths occurred in nursing homes with a night shift nurse versus 12 in those without one (p<0001). CONCLUSIONS The location of the death of frail elderly patients is a major health issue that needs to be addressed. Our results suggests that the presence of a night shift nurse decreases the number of emergency transfers and deaths in the hospital.
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Affiliation(s)
| | | | | | - Murielle Ruer
- Palliative Care, Hospices Civils de Lyon, Lyon, France
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15
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Bally KW, Krones T, Jox RJ. Advance Care Planning for People with Dementia: The Role of General Practitioners. Gerontology 2019; 66:40-46. [PMID: 31212289 DOI: 10.1159/000500809] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022] Open
Abstract
General practitioners (GPs) play a key role in the timely diagnosis of dementia and also in advance care planning (ACP). They often have known patients and their families for decades and are familiar with their values and treatment preferences; they are, therefore, in a position to initiate the ACP process even before the appearance of the first symptoms of dementia and certainly following disclosure of the diagnosis. To do so, they should recognise whether patients are receptive to an ACP consultation or whether they might reject it for personal, social or cultural reasons. Under no circumstances should the patient or their family be coerced into making these provisions. In most countries, the current framework does not provide enough time and money for GPs to carry out actual ACP consultations completely on their own. There is evidence that specially trained health professionals are able to more effectively discuss treatment goals and limits of life-prolonging measures than GPs who are well acquainted with their patients. Consequently, we suggest that it will be the GPs' task to seize the right moment for starting an ACP process, to raise awareness of patients and their relatives about ACP, to test the patient's decision-making capacity and, finally, to involve appropriately trained healthcare professionals in the actual ACP consultation process. Care should be taken that these professionals delivering time-intensive ACP consultations are not only able to reflect on the patient's values but are also familiar with the course of the disease, the expected complications and the decisions that can be anticipated. The GP will ensure an active exchange with the ACP professional and should have access to the documentation drawn up in the ACP consultation process (treatment plan and advance directive including instructions for medical emergencies) as soon as possible. GPs as coordinators of healthcare provision should document appropriately all specialists involved in the care and ensure that treatment decisions are implemented in accordance with the patient's preferences for future care or the presumed will of the patient.
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Affiliation(s)
- Klaus W Bally
- Centre for Primary Health Care, University of Basel, Basel, Switzerland,
| | - Tanja Krones
- Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zürich, Switzerland
| | - Ralf J Jox
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Goossens B, Sevenants A, Declercq A, Van Audenhove C. 'We DECide optimized' - training nursing home staff in shared decision-making skills for advance care planning conversations in dementia care: protocol of a pretest-posttest cluster randomized trial. BMC Geriatr 2019; 19:33. [PMID: 30717700 PMCID: PMC6360673 DOI: 10.1186/s12877-019-1044-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Due to the gradual loss of function, it is crucial for persons with dementia to discuss advance care planning in due course. However, nursing home staff, residents and their families feel uncomfortable to start this type of conversation, resulting in unknown (care) preferences. ‘We DECide optimized’ will provide tools to nursing home staff for discussing advance care planning. The primary objective is to enhance the level of shared decision-making in advance care planning conversations. We hypothesize that the training will enhance the perception of the importance, competence and frequency in which participants engage in advance care planning conversations. The secondary objective is to assess barriers and facilitators in the implementation of advance care planning policies at the ward level. Methods ‘We DECide optimized’ will consist of two four-hour workshops and a homework assignment between sessions. Training components will include information on advance care planning and shared decision-making, role-play exercises and group discussions on implementation barriers at the ward level. Participating wards will receive supporting materials to stimulate residents and their families to initiate conversations. The study uses a cluster randomized controlled design, with 65 Flemish nursing home wards taking part (311 staff members). Data will be collected through a pretest-posttest model, with measurements up to 9 months after training. The RE-AIM framework will be used to evaluate the effectiveness of the implementation. Quantitative and qualitative data at the clinical, organizational and resident level will be collected. Discussion This study describes a hands-on, in-depth and multi-level training approach to improve shared decision-making in advance care planning conversations. By providing tools to ward staff, engaging the management and informing residents and their families, ‘We DECide optimized’ aims to decrease evidence-based barriers and to provide all stakeholders with incentives to engage in conversations about (care) preferences in an informative and participatory manner. Electronic supplementary material The online version of this article (10.1186/s12877-019-1044-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bart Goossens
- LUCAS, KU Leuven, Minderbroedersstraat 8, 3000, Leuven, Belgium.
| | - Aline Sevenants
- LUCAS, KU Leuven, Minderbroedersstraat 8, 3000, Leuven, Belgium
| | - Anja Declercq
- LUCAS, KU Leuven, Minderbroedersstraat 8, 3000, Leuven, Belgium
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17
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Abstract
ABSTRACTThe purpose of this study was to analyse the consistency and extent of palliative content across high-level guiding documents related to the care of persons residing in Canadian long-term care homes. A systematic search was conducted examining documents at the national level and across five provinces (Alberta, Ontario, Saskatchewan, Manitoba, and Quebec). Twenty-five documents were selected based on inclusion criteria from 273 documents identified in the systematic search. The majority of these documents were created nationally (48%) or in Ontario (28%). Documents varied in palliative topics discussed, and long-term care was discussed minimally. A minimal number of palliative care guiding documents were found. Long-term care specific documents were absent, and all documents lacked consistency on palliative topics. It is imperative that palliative principles are present and consistent in high-level documents in order to improve the quality of life and care for long-term care residents across Canada.
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Midtbust MH, Alnes RE, Gjengedal E, Lykkeslet E. Perceived barriers and facilitators in providing palliative care for people with severe dementia: the healthcare professionals' experiences. BMC Health Serv Res 2018; 18:709. [PMID: 30208872 PMCID: PMC6134769 DOI: 10.1186/s12913-018-3515-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/30/2018] [Indexed: 12/03/2022] Open
Abstract
Background Dementia has become a major public health issue worldwide due to its rapidly increasing prevalence and an increasing number of dementia-related deaths in long-term care facilities. The aim of this study was to examine health professionals’ experiences of potential barriers and facilitators in providing palliative care for people with severe dementia in long-term care facilities. Methods This was a qualitative descriptive study. The data were collected from four focus groups and 20 individual in-depth interviews with healthcare professionals from four Norwegian nursing homes. The data were analysed by thematic text analysis, as described by Braun and Clarke. Results The major findings indicate that healthcare professionals experience a lack of continuity as the main barrier to facilitating palliative care. Time pressure and increased efficiency requirements especially affect the weakest and bedridden residents with dementia. The healthcare professionals feel conflicted between wanting to spend more time caring for each individual resident and feeling pressure to help everyone. Although resources are scarce, dying residents are always given priority by healthcare professionals, either by the hiring of extra personnel or the reorganization of tasks in a way that facilitates someone staying with the terminal resident. Advanced care planning was highlighted as a facilitator in providing palliative care, but the extensive use of temporary staff among nurses and doctors and the relocation between the sheltered and long-term wards threaten the continuity in planning and providing palliative care. Conclusions The findings indicate that healthcare professionals experienced several structural barriers that prevented the provision of palliative care to people with severe dementia in long-term care facilities. Increasing demands for economic rationality lead to a lack of continuity of care. Organizational changes, such as measures to increase the competence and the proportion of permanent employees and the prevention of burdensome end-of-life transitions, should be implemented to improve continuity and quality of care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3515-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- May Helen Midtbust
- Faculty of Medicine and Health Sciences, Department for Health Sciences in Aalesund, Norwegian University of Science and Technology, Box 1517, NO 6025, Aalesund, Norway.
| | - Rigmor Einang Alnes
- Faculty of Medicine and Health Sciences, Department for Health Sciences in Aalesund, Norwegian University of Science and Technology, Box 1517, NO 6025, Aalesund, Norway
| | - Eva Gjengedal
- University of Bergen, Global Public Health and Primary Care, Box 7804, 5020, Bergen, Norway.,Faculty of Health Sciences and Social Care, Molde University College, Box 2110, NO 6402, Molde, Norway
| | - Else Lykkeslet
- Faculty of Health Sciences and Social Care, Molde University College, Box 2110, NO 6402, Molde, Norway
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19
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Beck ER, McIlfatrick S, Hasson F, Leavey G. Nursing home manager's knowledge, attitudes and beliefs about advance care planning for people with dementia in long-term care settings: a cross-sectional survey. J Clin Nurs 2017; 26:2633-2645. [DOI: 10.1111/jocn.13690] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Esther-Ruth Beck
- Institute of Nursing and Health Research; University of Ulster; Newtownabbey UK
| | - Sonja McIlfatrick
- All Ireland Institute of Hospice and Palliative Care; University of Ulster; Newtownabbey UK
| | | | - Gerry Leavey
- University of Ulster and Bamford Centre for Mental Health; Londonderry UK
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20
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Dröes RM, Chattat R, Diaz A, Gove D, Graff M, Murphy K, Verbeek H, Vernooij-Dassen M, Clare L, Johannessen A, Roes M, Verhey F, Charras K. Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice. Aging Ment Health 2017; 21:4-17. [PMID: 27869503 DOI: 10.1080/13607863.2016.1254596] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Because the pattern of illnesses changes in an aging population and many people manage to live well with chronic diseases, a group of health care professionals recently proposed reformulating the static WHO definition of health towards a dynamic one based on the ability to physically, mentally and socially adapt and self-manage. This paper is the result of a collaborative action of the INTERDEM Social Health Taskforce to operationalize this new health concept for people with dementia, more specifically the social domain, and to formulate directions for research and practice to promote social health in dementia. METHOD Based on the expertise of the Social Health Taskforce members (N = 54) three groups were formed that worked on operationalizing the three social health dimensions described by Huber et al.: (1) capacity to fulfil potential and obligations; (2) ability to manage life with some degree of independence; (3) participation in social activities. For each dimension also influencing factors, effective interventions and knowledge gaps were inventoried. After a consensus meeting, the operationalizations of the dimensions were reviewed by the European Working Group of People with Dementia (EWGPWD). RESULTS The social health dimensions could be well operationalized for people with dementia and are assessed as very relevant according to the Social Health Taskforce and EWGPWD. Personal (e.g. sense of coherence, competencies), disease-related (e.g. severity of cognitive impairments, comorbidity), social (support from network, stigma) and environmental factors (e.g. enabling design, accessibility) that can influence the person with dementia's social health and many interventions promoting social health were identified. CONCLUSION A consensus-based operationalization of social health in dementia is proposed, and factors that can influence, and interventions that improve, social health in dementia identified. Recommendations are made for research and practice.
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Affiliation(s)
- R M Dröes
- a Department of Psychiatry, Alzheimer Centre , EMGO Institute for Health and Care Research, VU University Medical Centre , Amsterdam , The Netherlands
| | - R Chattat
- b Department of Psychology , University of Bologna , Bologna , Italy
| | - A Diaz
- c Alzheimer Europe , Luxembourg , Luxembourg
| | - D Gove
- c Alzheimer Europe , Luxembourg , Luxembourg
| | - M Graff
- d Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud Alzheimer Centre , Nijmegen , The Netherlands
| | - K Murphy
- e School of Nursing and Midwifery, Aras Loyola, National University of Irelands , Galway , Ireland
| | - H Verbeek
- f Research School CAPHRI, Department of Health Services Research , Maastricht University , Maastricht , The Netherlands
| | - M Vernooij-Dassen
- d Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud Alzheimer Centre , Nijmegen , The Netherlands
| | - L Clare
- g Centre for Research in Ageing and Cognitive Health (REACH) , School of Psychology, University of Exeter, and PenCLAHRC, University of Exeter Medical School , Exeter , United Kingdom
| | - A Johannessen
- h Norwegian National Advisory Unit on Ageing and Health , VID Specialized University , Oslo , Norway
| | - M Roes
- i German Center for Neurodegenerative Diseases, Department of Nursing Science, Faculty of Health , University of Witten/Herdecke , Witten , Germany
| | - F Verhey
- j Department of Psychiatry and Neuropsychology , Maastricht University , Maastricht , The Netherlands
| | - K Charras
- k Fondation Médéric Alzheimer , Psychosocial Interventions Department , Paris , France
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21
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Mariani E, Vernooij-Dassen M, Koopmans R, Engels Y, Chattat R. Shared decision-making in dementia care planning: barriers and facilitators in two European countries. Aging Ment Health 2017; 21:31-39. [PMID: 27869501 DOI: 10.1080/13607863.2016.1255715] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Shared decision-making (SDM) is a means of allowing people with dementia to take part in making choices, be autonomous and participate in social activities. Involving them in SDM is an important way of promoting social health. However, including families and dementia residents in decision-making can be challenging for care staff working in nursing homes. The objective of this study was to identify barriers and facilitators regarding the implementation of an SDM framework for care planning in two nursing homes, one in Italy and one in the Netherlands. METHODS Focus group interviews were conducted with healthcare professionals who, after being trained, applied the SDM framework. Content analysis was used to analyze the data. RESULTS Six months after the feasibility trial, focus group interviews with healthcare professionals (n = 10 in Italy; n = 9 in the Netherlands) were held. We found 6 themes and 15 categories. Within these themes, facilitators and barriers were identified. The categories of team collaboration, communication skills and nursing home policy were found to be facilitators to the implementation process, whereas regulations, lack of funding and of involvement of family caregivers were the main barriers. Family attitudes towards SDM could be both. The main difference between countries concerned the residents' cognitive status that influenced their degree of involvement. CONCLUSION Communication skills training for professionals, training of family caregivers, and involvement of the management in the implementation process seem to be crucial factors in successfully implementing SDM in nursing homes, and increasing the involvement of families and dementia residents in decision-making.
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Affiliation(s)
- Elena Mariani
- a Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre , Nijmegen , The Netherlands.,b Department of Psychology, Alma Mater Studiorum , University of Bologna , Bologna , Italy
| | - Myrra Vernooij-Dassen
- a Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre , Nijmegen , The Netherlands.,c Kalorama Foundation , Beek-Ubbergen , The Netherlands.,d Radboud Alzheimer Center
| | - Raymond Koopmans
- d Radboud Alzheimer Center.,e Department of Primary and Community Care , Radboud University Medical Centre , Nijmegen , The Netherlands.,f Joachim & Anna, Center for Specialized Geriatric Care , Nijmegen , The Netherlands
| | - Yvonne Engels
- g Department of Anaesthesiology, Pain and Palliative Medicine , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Rabih Chattat
- b Department of Psychology, Alma Mater Studiorum , University of Bologna , Bologna , Italy
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