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De Veer AJE, Voss H, Francke AL, de Man Y. Improvement of palliative care for people with intellectual disabilities: A multi-site evaluation. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13223. [PMID: 38469929 DOI: 10.1111/jar.13223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/23/2023] [Accepted: 02/20/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND To improve the quality of palliative care, six evidence-based tools were implemented in 10 care services specialised in care for people with intellectual disabilities. Contextual differences were taken into account by using a participatory action research approach. METHOD The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance) structured the evaluation. Data sources were online questionnaires completed by 299 professionals at baseline (response 45.2%) and 250 professionals after 2.5 years (35.1%), 11 semi-structured group interviews with 43 professionals, field notes and implementation plans. RESULTS A total of 767 professionals and 43 teams were reached. The effectiveness of the intervention was demonstrated in an improved knowledge of palliative care policy and increased competences among professionals. 79% of the professionals adopted tools in the toolbox. The participatory action research method was perceived as valuable in driving change. CONCLUSIONS Improving palliative care needs a context-specific, flexible approach, with involvement of all stakeholders.
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Affiliation(s)
- Anke J E De Veer
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Hille Voss
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Anneke L Francke
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, APH Amsterdam Public Health research institute, Amsterdam, The Netherlands
- Expertise Centre Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Y de Man
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Öztürk ME, Yabanci Ayhan N. The relationship between the severity of intellectual and developmental disabilities (IDDs) in adults with IDDs and eating and drinking problems and nutritional status. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2024; 68:325-339. [PMID: 38183317 DOI: 10.1111/jir.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Adults with intellectual and developmental disabilities (IDDs) experience eating, drinking and swallowing problems, such as chewing problems, choking, gagging, coughing during eating, aspiration and rumination syndrome, which may lead to poor nutritional status. This study aimed to determine the relationship between IDD levels, eating, drinking and swallowing problems and nutritional status in adults with IDDs. METHODS The sample consisted of 71 participants (37 men and 34 women) with a mean age of 22.5 ± 7 years (range 18-60 years). Professionals classified intellectual disability as mild, moderate or severe. The Screening Tool of Feeding Problems scale was applied to the caregivers of adults with IDDs to identify eating, drinking and swallowing problems. Dietary intake was assessed using a 24-h dietary recall and a food and nutrition photograph catalogue. The researchers measured body weight, height and middle upper arm circumference. Body mass index was calculated. Four body mass index categories were determined: underweight (<18.5 kg/m2 ), normal weight (18.5-24.9 kg/m2 ), overweight (25.0-29.9 kg/m2 ) and obese (≥30 kg/m2 ). Chi-squared tests were used to detect the relationship between IDD levels and eating and drinking problems, and analysis of variance tests were conducted to detect the relationship between IDD levels with anthropometric measurements and dietary intake. RESULTS Participants had mild (42.3%; n = 30), moderate (29.6%; n = 21) or severe IDD (28.2%; n = 20). They were underweight (12.7%; n = 9), normal weight (59.2%; n = 42) or overweight and/or obese (28.2%; n = 20). Participants with severe IDD had significantly higher Screening Tool of Feeding Problems 'nutrition-related behaviour' and 'eating and drinking skill deficit problem' sub-scale scores than those with mild IDD. However, the groups had no significant difference in 'food refusal and selectivity' sub-scale scores. Participants with severe IDD also had anorexia prevalence similar to those with mild IDD. The groups did not significantly differ in anthropometric measurements, daily energy intake and macronutrient and micronutrient intake. CONCLUSIONS While adults with severe IDD had more eating and drinking skill deficits (e.g. chewing problems and independent eating difficulties) and nutrition-related behaviour problems than those with mild IDD, the eating, drinking and swallowing problems, which may critically affect their food intake, were similar to adults with mild IDD. The anthropometric measurements and energy and nutrient intakes of adults with severe IDD were not significantly different from those with mild IDD consistently. Findings indicate that nutritional deficiencies and nutritional behaviour problems may be avoidable in adults with IDDs.
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Affiliation(s)
- M E Öztürk
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Karamanoğlu Mehmetbey University, Karaman, Turkey
| | - N Yabanci Ayhan
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, Turkey
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Diaz MA, Angus FC, Bickenbach JE. Perceived barriers and facilitators to good end of life care: Focusing on people with intellectual disabilities. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13186. [PMID: 38097500 DOI: 10.1111/jar.13186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/25/2023] [Accepted: 12/01/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND People with intellectual disabilities are often left out of research on important topics. This exploratory study investigated their views on barriers and facilitators to accessing care at end of life, both at home and in a hospice setting. METHOD This qualitative study used reflexive thematic analysis. Two focus groups were held via Zoom with a total of four participants. RESULTS Three themes were produced: Unsettling Transitions, Maintaining Familiarity, and Respecting People's Wishes. Keeping things as unchanged as possible at end of life was highlighted as an ideal. Respecting people's wishes and education were highlighted as facilitators to good end of life care. CONCLUSIONS The themes identified in this study highlight the fears and wishes of this population with regards to receiving quality end of life care. Training for staff and families, as well as advanced care planning, could focus on enhancing facilitators and decreasing barriers for this population.
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Affiliation(s)
| | | | - Jerome E Bickenbach
- Swiss Paraplegic Research, Nottwil, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Diaz MA, Bickenbach JE, Sabariego C, Bernard RM. Qualitative methodological approaches involving participants with intellectual disabilities: Scoping review of literature exploring death and dying. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13119. [PMID: 37315942 DOI: 10.1111/jar.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/20/2023] [Accepted: 05/08/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND A paucity of qualitative research on sensitive topics that focuses on participants with intellectual disabilities leaves their views unexplored. This scoping review mainly aimed to provide an overview of qualitative data collection methods used in research involving participants with intellectual disabilities to explore death and dying. METHOD A scoping review of primary research and methodological papers published between January 2008 and March 2022 was conducted. The PRISMA-ScR checklist was followed. RESULTS We identified 25 articles utilising four data collection methods: interviews, focus groups, the Nominal Group Technique, and participant observation. Data collection trends were identified, including accommodations for participants with intellectual disabilities, visual media used as a facilitator, and reporting of distress protocols. Most participants had mild to moderate intellectual disabilities. CONCLUSIONS The included studies demonstrate a flexible approach that relies on the use of multiple methods. Future research must adequately report study characteristics to ensure transparency and reliability.
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Affiliation(s)
| | | | - Carla Sabariego
- Swiss Paraplegic Research, Nottwil, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Center for Rehabilitation in Global Health Systems, WHO Collaborating Center, University of Lucerne, Lucerne, Switzerland
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Voss H, Francke AL, de Veer AJE. Improving palliative care for people with intellectual disability: a self-assessment of policies, practices and competencies in care services. BMC Palliat Care 2023; 22:103. [PMID: 37481535 PMCID: PMC10362573 DOI: 10.1186/s12904-023-01224-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/12/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Providing care for ageing and vulnerable people with intellectual disability (ID) is challenging, and professionals working in ID care often have limited experience in palliative care. The current study provides insight into palliative care practices in ID care services and competencies of professionals and identifies ways to improve palliative care for people with ID. METHODS For this study ten services in the Netherlands were recruited that provide care for people with mild to profound ID. Professionals in each of these services conducted a self-assessment of their palliative care policies and practices based on nine core element of palliative care described in the Dutch Quality Framework for Palliative Care. The self-assessment included a medical file review of a total of 100 people with ID who died non-suddenly. In addition, 424 professionals from the services returned a digital questionnaire on palliative care competencies and training needs. RESULTS The self-assessments showed that individual care plans were recorded for people with ID and that multidisciplinary teams provided physical, psychological, social and spiritual care. However, other core elements of palliative care, such as cooperation with other organisations and expertise in palliative care, were less present in ID care services. Only half of the services collaborated with regional organisations in palliative care, and most services listed no requirements for the palliative care skills of their professionals. The questionnaire showed that almost 10% of the professionals reported that they were not at all competent in providing palliative care, and 74% felt that they needed training in palliative care. Reported areas for improvement in the provision of palliative care were increasing the quality of palliative care, improving the expertise of professionals and identifying palliative care needs earlier. CONCLUSIONS To improve palliative care in ID care services changes are required both in competencies of professionals, and organisational policies and practices. Services should enhance awareness about palliative care for people with ID, strengthen collaboration with palliative care services, and offer training or support for professionals in assessing and meeting the needs of people with ID at the end of life.
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Affiliation(s)
- Hille Voss
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN, The Netherlands
| | - Anneke L Francke
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, APH Amsterdam Public Health research institute, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands
| | - Anke J E de Veer
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN, The Netherlands.
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Wiese MY, Stancliffe RJ, Durvasula S, Piepers DW, Wilson NJ. Analysis of an Australian death database of people with intellectual disability living out of the family home: Place of death and associated variables. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2023:17446295231175541. [PMID: 37192146 DOI: 10.1177/17446295231175541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
This study reports on a five-year data set about the deaths of 599 individuals in New South Wales Australia, who at the time of their death were living in out-of-home care. Analysis aimed to: i) gain a clearer understanding of place of death for people with intellectual disability; and ii) identify and analyse associated variables to investigate how well they predict place of death for this population. Hospital admissions, polypharmacy and living situation were the strongest standalone predictors of place of death. A hospital death was more likely if the target population were subject to polypharmacy, lived in a group home, had a moderate intellectual disability or had GORD. Death, and place of death, is an issue requiring individual consideration. This study has identified some of the variables that need attention when supporting people with intellectual disability to have a good death.
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Affiliation(s)
| | - Roger J Stancliffe
- Sydney School of Health Sciences, Centre for Disability Research and Policy, The University of Sydney, Australia
| | - Seeta Durvasula
- Sydney Medical School, Centre for Disability Studies, The University of Sydney, Australia
| | | | - Nathan J Wilson
- School of Nursing and Midwifery, Western Sydney University, Australia
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McMahon MJ, O'Connor AM, Dunbar P, Delany A, Behan L, Grogan C, Keyes LM. Mortality in residential care facilities for people with disability: a descriptive cross-sectional analysis of statutory notifications in Ireland. BMJ Open 2023; 13:e065745. [PMID: 37147100 PMCID: PMC10163474 DOI: 10.1136/bmjopen-2022-065745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To determine incidence of death in residential care facilities for people with disability in Ireland, primary cause of death, associations of facility characteristics and deaths, and to compare characteristics of deaths reported as expected and unexpected. DESIGN Descriptive cross-sectional study. SETTING All residential care facilities for people with disability operational in Ireland in 2019 and 2020 (n=1356). PARTICIPANTS n=9483 beds. MAIN OUTCOME MEASURES All expected and unexpected deaths notified to the social services regulator. Cause of death as reported by the facility. RESULTS 395 death notifications were received in 2019 (n=189) and 2020 (n=206). 45% (n=178) were for unexpected deaths. Incidence of death per 1000 beds per year was 20.83 for all, 11.44 for expected and 9.39 for unexpected deaths. Respiratory disease was the most common cause of death, accounting for 38% (n=151) of all deaths. In adjusted negative binomial regression analysis, congregated settings versus non-congregated (incidence rate ratio (95% CI): 2.59 (1.80 to 3.73)) and higher bed numbers (highest vs lowest quartile) (4.02 (2.19 to 7.40)) were positively associated with mortality. There was also a positive n-shaped association with category of nursing staff-to-resident ratio when compared with zero nurses. Emergency services were contacted for 6% of expected deaths. Of the deaths reported as unexpected, 29% were receiving palliative care and 10.8% had a terminal illness. CONCLUSION Although incidence of death was low, residents of congregated and larger settings had higher incidence of death than residents of other settings. This should be a consideration for practice and policy. Given the high contribution of respiratory diseases to deaths and the potential avoidability of these, there is a need for improved respiratory health management in this population. Nearly half of all deaths were reported as unexpected; however, overlap in the characteristics of expected and unexpected deaths highlights the need for clearer definitions.
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Affiliation(s)
- Martin J McMahon
- Health Information Quality Authority, Mahon, Cork, Ireland
- School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin 2, Ireland
- Trinity Centre for Ageing and Intellectual Disability, School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin 2, Ireland
| | | | - Paul Dunbar
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Anna Delany
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Laura Behan
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Carol Grogan
- Health Information Quality Authority, Mahon, Cork, Ireland
| | - Laura M Keyes
- Health Information Quality Authority, Mahon, Cork, Ireland
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Moore CM, Pan CX, Roseman K, Stephens MM, Bien-Aime C, Morgan AC, Ross W, Castillo MC, Palathra BC, Jones CA, Ailey S, Tuffrey-Wijne I, Smeltzer SC, Tobias J. Top Ten Tips Palliative Care Clinicians Should Know About Navigating the Needs of Adults with Intellectual Disabilities. J Palliat Med 2022; 25:1857-1864. [PMID: 36083260 DOI: 10.1089/jpm.2022.0384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
As many people with intellectual disabilities (ID) live longer, the need for access to quality palliative care (PC) rises. People with ID realize significant barriers and inequities in accessing health care and PC. The need for integrated disability and PC services with extensive collaboration is great. The following tips are for PC clinicians caring for people with ID, their families, caregivers, and the community. While patient-centered care is difficult to distill into "tips," this article, written by an interdisciplinary team of PC and ID specialists, offers resources and references to improve the care provided to people with ID and serious illnesses.
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Affiliation(s)
- Caitlyn M Moore
- Jefferson College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Inpatient Palliative Care and Hospice, Main Line Health, Radnor, Pennsylvania, USA
| | - Cynthia X Pan
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens Hospital, Flushing, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Karin Roseman
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Jefferson Continuing Care Program, Jefferson Health, Philadelphia, Pennsylvania, USA
| | - Mary M Stephens
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Jefferson Continuing Care Program, Jefferson Health, Philadelphia, Pennsylvania, USA
| | - Casey Bien-Aime
- Pastoral Care Department, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
| | - Ann C Morgan
- New York State Office for People with Developmental Disabilities, Region 6, Queens, New York, USA
| | - Wendy Ross
- Jefferson Center for Autism and Neurodiversity, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Matthew C Castillo
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens Hospital, Flushing, New York, USA
| | - Brigit C Palathra
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens Hospital, Flushing, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah Ailey
- Department of Community, Systems, and Mental Health Nursing, Rush University, College of Nursing, Chicago, Illinois, USA
| | - Irene Tuffrey-Wijne
- Center for Health and Social Care Research, Kingston University, University of London, London, United Kingdom
| | - Suzanne C Smeltzer
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
| | - Jane Tobias
- Jefferson College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Velepucha-Iniguez J, Bonilla Sierra P, Bruera E. Barriers to Palliative Care Access in Patients With Intellectual Disability: A Scoping Review. J Pain Symptom Manage 2022; 64:e347-e356. [PMID: 35995282 DOI: 10.1016/j.jpainsymman.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/12/2022] [Accepted: 08/11/2022] [Indexed: 01/04/2023]
Abstract
UNLABELLED There is limited knowledge about inequalities regarding palliative care access among patients with intellectual disability. The present scoping review aimed to identify the existing barriers that limit access to palliative care (PC) in patients with intellectual disability. METHODS We conducted a literature review on publications since 2014 from three databases (MEDLINE, Biomed Central, and Elsevier Scopus), along with hand searches in scientific journals. The review included peer-reviewed studies written in English and Spanish language with quantitative and qualitative study designs. The participants were patients with intellectual disability and health professionals who had worked with them or had experience in palliative care. RESULTS 22 studies met the selection criteria. The barriers identified were under referral to palliative care, reduced access, communication, and limited knowledge and experience by health professionals. CONCLUSION Patients with intellectual disability do not get referred to PC frequently. Health professionals and caregivers do not recognize when it is necessary to make a referral, and they need to improve their communication abilities. Also, health care workers need more training in PC, pain management, anticipation of death, and use of opioids. More research and education on the palliative care needs and care for patients with intellectual disabilities is needed.
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Affiliation(s)
- Josselyn Velepucha-Iniguez
- Department of Health Sciences (J.V.I., P.B.S.), Universidad Técnica Particular de Loja (UTPL), Loja, Ecuador.
| | - Patricia Bonilla Sierra
- Department of Health Sciences (J.V.I., P.B.S.), Universidad Técnica Particular de Loja (UTPL), Loja, Ecuador
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine (E.B.), The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Todd S, Bernal J, Worth R, Shearn J, Brearley S, McCarron M, Hunt K. Hidden lives and deaths: the last months of life of people with intellectual disabilities living in long-term, generic care settings in the UK. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 34:1489-1498. [PMID: 34031949 DOI: 10.1111/jar.12891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Abstract
RATIONALE This paper concerns mortality and needs for end-of-life care in a population of adults with ID living in generic care homes. METHODS Various sampling strategies were used to identify a difficult to find a population of people with ID in generic care homes. Demographic and health data were obtained for 132 people with ID. This included the Surprise Question. At T2, 12 months later, data were obtained on the survival of this sample. FINDINGS The average age was 68.6 years, and the majority were women (55.3%). Their health was typically rated as good or better. Responses to the Surprise Question indicated that 23.3% respondents might need EoLC. At T2, 18.0% of this population had died. The average of death was 72.2 years. The majority died within the care setting (62.9%). IMPLICATIONS The implications for end-of-life care and mortality research are discussed.
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What Constitutes Good Quality End‐of‐Life Care? Perspectives of People With Intellectual Disabilities and Their Families. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2021. [DOI: 10.1111/jppi.12376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bernal J, Hunt K, Worth R, Shearn J, Jones E, Lowe K, Todd S. Expecting the unexpected: measures, outcomes and dying trajectories for expected and unexpected death in adults with intellectual disabilities in social care settings in the UK. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 34:594-605. [DOI: 10.1111/jar.12827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/09/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Katherine Hunt
- School of Health Sciences University of Southampton Southampton UK
| | | | | | | | - Kathy Lowe
- University of South Wales Pontypridd UK
- Abertawe Bro Morgannwg University Health Board Wales UK
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