Components of palliative care interventions addressing the needs of people with dementia living in long-term care: A systematic review

The Effectiveness of Palliative Care Interventions in Long-Term Care Facilities: A Systematic Review

The increasing elderly population is driving higher utilization rates of long-term care facilities, where residents often have multiple chronic diseases, making them potential candidates for palliative care. Timely palliative care interventions can improve their quality of life and medical autonomy. This study systematically reviews the effectiveness of palliative care programs in long-term care facilities. Databases such as PubMed, EMBASE, Cochrane Library, and Airiti Library were searched up to 31 December 2023, using PICO criteria and the following keywords: 'care home', 'nursing home', 'residential aged care facility', and 'long-term care facility' for patients; and 'Gold Standard Framework in Care Homes', 'integrated care pathway', 'care home project', and 'palliative care program' for interventions. Seven articles were included. The results indicate that the Program of All-Inclusive Care for the Elderly (PACE) intervention did not significantly influence overall quality of life but did improve the quality of death. There were no statistical differences in comfort or quality of death between the dementia and non-dementia groups. However, PACE significantly reduced healthcare costs. The implementation of the Liverpool Care Pathway (LCP) notably enhanced the control of terminal symptoms, while the Gold Standard Framework in Care Homes (GSFCH) effectively improved end-of-life care rates, do-not-resuscitate (DNR) signing rates, advance care planning (ACP) completion rates, and reduced inappropriate readmission rates. While palliative care interventions are shown to improve the quality of end-of-life care, their practical application should be adapted to fit the implementation conditions and capabilities of domestic long-term care facilities.

Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

The PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life.

RESULTS

We captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters.

CONCLUSIONS AND IMPLICATIONS

By promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

'There's something they can do': Educating aged care staff about the trajectory of dementia, palliative care and the Namaste Care™ program: A mixed methods study

OBJECTIVE

To evaluate outcomes of education about the dementia illness trajectory and Namaste Care™ program on aged care staff's knowledge, attitudes, self-perceived skills and competence.

METHODS

A convergent mixed methods research design was adopted to compare the results of quantitative and qualitative data following an education intervention. Nurses and aged care staff (n = 35) undertook 2 × 2 h training sessions over 3 days. Data were collected pre- and post-intervention using three validated surveys. Qualitative data were collected through interviews and a focus group. Thematic analysis was used to generate themes. Quantitative and qualitative data were integrated and compared during interpretation and discussion of the findings.

RESULTS

Significant improvements in knowledge, attitudes and skills survey scores from already published data were confirmed by the qualitative findings in this study. Three key themes were derived from the data, comprising dementia-related education and knowledge changes, recognising the benefits of the Namaste Care™ program, and the importance of changing practice.

CONCLUSIONS

Dementia education using the Namaste Care™ program enabled staff to identify gaps in knowledge and skills within their own practice. Staff perceived that the Namaste Care™ program can be a driver for practice change including palliative care to improve quality of life for people living in the advanced stages of dementia.

Characterizing Canadian Social Workers Willing to Be Involved in Medical Assistance in Dying for Persons Lacking Decisional Capacity

Medical assistance in dying (MAID) is available in Canada for competent persons meeting the legal requirements. Extending access to persons lacking decisional capacity is being considered. Social workers may be called upon to accompany these persons through the MAID process. As part of a larger survey, we asked social workers from Quebec whether they would be willing to be involved should advance requests for MAID be legalized. Of the 367 respondents, 291 replied that they would. Using multivariable logistic regression, we identified characteristics that distinguish them from the other social workers surveyed: importance of religious or spiritual beliefs, being born in Canada, having received assisted-death requests from families, professional experiences with MAID, and dreading the prospect of participating in MAID for persons lacking decisional capacity. These findings underline the need for educational interventions that would increase social workers' confidence in providing high-quality care to clients who opt for MAID.

Advanced-Comfort: Usability Testing of a Care Planning Intervention for Nursing Home Residents With Advanced Dementia

Many nursing home (NH) residents with advanced dementia receive burdensome interventions rather than interventions that promote comfort or quality of life. The purpose of the current study was to test the usability of a novel intervention, ADVANCED-Comfort, which aims to enhance the provision of personalized care for residents with advanced dementia. The intervention comprises structured care plan meetings between the NH team and proxies of residents with dementia (e.g., family members). Using the ADVANCED-Comfort workbook, proxies create individualized care plans addressing six domains adapted from the Age-Friendly Health System Framework. The purpose of this article is to describe the intervention and its theoretical underpinnings and report the usability of the intervention evaluated with surveys, observation, and exit interviews. The study demonstrated that proxies and NH staff found the intervention usable (acceptable, appropriate, and feasible). Based on these preliminary findings, additional testing of the ADVANCED-Comfort intervention is warranted. [Journal of Gerontological Nursing, 49(11), 15-23.].

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Palliative care for people with dementia

Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.

South African speech-language therapists' practices regarding feeding tube placement in people with advanced dementia

BACKGROUND

 Studies related to tube feeding in people with dementia (PWD) remain a contested topic, neglecting the importance of speech-language therapists' (SLTs) role in dysphagia management. Furthermore, SLT practices and beliefs regarding tube feeding in people with advanced dementia in an upper-middle-income country, such as South Africa, are unexplored.

OBJECTIVE

 This study aimed to determine the practices and beliefs of SLTs in South Africa regarding tube feeding placement in PWD.

METHOD

 A self-compiled online survey was distributed using social media platforms and was completed by 83 South African SLTs with experience in swallowing and feeding management of PWD.

RESULTS

 Most SLTs (78.8%) strongly believed they play a vital role in the decision-making regarding feeding tube insertion in PWD. This role is often met with several challenges, such as limited support from other healthcare professionals. Speech-language therapists with more experience and increased involvement in palliative care appeared to be more confident in supporting and counselling families of PWD on tube feeding. Many SLTs still recommend tube feeding despite its known negative consequences for PWD.

CONCLUSION

 The findings indicate a need for continued professional development for South African SLTs on feeding decisions in advanced dementia to increase knowledge and confidence in clinical practice. Speech-language therapists require guidelines by professional bodies and further dialogue amongst healthcare professionals to guide difficult feeding decisions in people with advanced dementia.

Informal care-givers' attitudes towards medical assistance in dying for persons with dementia

Medical assistance in dying (MAID) is legal in Canada but cannot be accessed through an advance request. Some data suggest that informal care-givers of persons with dementia support the legalisation of advance requests for MAID. Opponents argue that care-givers' support is due to society's failure to address their well-documented burden and unmet needs. To our knowledge, this assumption has never been tested. To fill this knowledge gap, we conducted a survey among 204 Canadian informal care-givers of persons with dementia to (a) elicit their attitudes towards allowing no longer competent adults to access MAID through an advance request, and (b) test the hypothesis that attitudes are in part driven by the level of burden experienced by care-givers and unmet needs for support. Attitudes were elicited with a clinical vignette involving a woman with Alzheimer's disease who requests MAID while still competent, or through an advance request for the time after she would lose decisional capacity. Informal care-givers' support for MAID ranged from 60 per cent in the scenario where the person is still competent and likely has several more years to live, to 87 per cent when she is depicted as no longer competent, in severe distress and close to death. Quality-of-life considerations and the value of self-determination were key arguments in support of legalising advance requests for MAID. Using multivariable logistic regression, we found no evidence that burden and unmet support needs influence attitudes towards advance requests for MAID, after controlling for other determinants. These findings contribute new insights into people's attitudes towards the sensitive issue of whether MAID should be extended to persons with dementia-induced decisional incapacity.

A qualitative comparison of care home staff and palliative care specialists' experiences of providing end of life care to people living and dying with dementia in care homes in two countries: A focus group study

BACKGROUND

Palliative care for people with dementia dying in care homes is an important aspect of long-term care. Whilst there is consensus about the principles of palliative care, less is known about how care home staff negotiate and influence decisions around end of life and how organisational context shapes that process.

AIM

To explore the views and experiences of care home staff and palliative care specialists on end of life care in care homes and understand how care home settings affected palliative care provision in England and Australia.

DESIGN/PARTICIPANTS

Eight focus groups in Australia and England with care home staff and palliative care specialists (n = 49). Reflexive thematic analysis was undertaken.

FINDINGS

Australian participants reported collaboration between care home staff, visiting professions and family members though case conferences. English participants discussed resident-focussed involvement from specialists that was less formally organised. Negotiating roles and responsibilities in end of life care; the importance of relationships to overcome deficiencies in formal processes; and the legitimacy and authority of advance care planning at times of crisis were recurring themes. The organisation and embedding of end of life care in processes and practices of care homes differed; this closely linked to care home procedures in Australia but was less apparent in England.

CONCLUSION

In both countries, partnership working was recognised and valued as key to effective palliative care. Work that enables care home staff to identify challenges with visiting professionals, such as agreeing priorities for care and negotiating their shared responsibilities, may lead to context-sensitive, sustainable solutions.

Earlier initiation of palliative care in the disease trajectory of people living with dementia: a scoping review protocol

INTRODUCTION

While the need for palliative care for people living with dementia has widely been recognised, they continue to be a disadvantaged group when it comes to timely initiation, and controversies remain regarding appropriate timing, or what elements constitute high quality palliative care early in the disease trajectory. To date, no literature review has summarised this debate or offered insights. The aim of this scoping review is to provide a general overview of research regarding palliative care in mild or moderate dementia, to identify existing controversies, and to examine what are key components of palliative care in dementia, specifically when initiated earlier in the disease trajectory.

METHODS AND ANALYSIS

Consistent with recent guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we carried out a search for academic literature in PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, Web of Science; on 5 November 2019 and an updated search on 2 February 2021. We will include studies with different study designs published in English over the last decade that focused on palliative care in early stages of dementia. We will include models targeting at least one outcome domain of palliative care (physical, psychological, social or spiritual) and advance care planning, and will exclude hospice models with limited prognosis similar to the requirements in the USA. We will report study characteristics and quality. We aim to apply narrative synthesis techniques to develop a theoretical model of how, for whom and why palliative care can be relevant in early stages of dementia, and what are facilitators and barriers. We anticipate to also describe if and how the concept of (early) palliative care in dementia changed across time and studies.

ETHICS AND DISSEMINATION

No ethical review required. Results will identify research gaps and lay out basic principles for conceptualising palliative care in early stages of dementia.

Multi-disciplinary supportive end of life care in long-term care: an integrative approach to improving end of life

Background

Optimal supportive end of life care for frail, older adults in long term care (LTC) homes involves symptom management, family participation, advance care plans, and organizational support. This 2-phase study aimed to combine multi-disciplinary opinions, build group consensus, and identify the top interventions needed to develop a supportive end of life care strategy for LTC.

Methods

A consensus-building approach was undertaken in 2 Phases. The first phase deployed modified Delphi questionnaires to address and transform diverse opinions into group consensus. The second phase explored and prioritized the interventions needed to develop a supportive end of life care strategy for LTC. Development of the Delphi questionnaire was based on findings from published results of physician perspectives of barriers and facilitators to optimal supportive end of life care in LTC, a literature search of palliative care models in LTC, and published results of patient, family and nursing perspectives of supportive end of life care in long term care. The second phase involved World Café Style workshop discussions. A multi-disciplinary purposive sample of individuals inclusive of physicians; staff, administrators, residents, family members, and content experts in palliative care, and researchers in geriatrics and gerontology participated in round one of the modified Delphi questionnaire. A second purposive sample derived from round one participants completed the second round of the modified Delphi questionnaire. A third purposive sample (including participants from the Delphi panel) then convened to identify the top priorities needed to develop a supportive end-of-life care strategy for LTC.

Results

19 participants rated 75 statements on a 9-point Likert scale during the first round of the modified Delphi questionnaire. 11 participants (participation rate 58 %) completed the second round of the modified Delphi questionnaire and reached consensus on the inclusion of 71candidate statements. 35 multidisciplinary participants discussed the 71 statements remaining and prioritized the top clinical practice, communication, and policy interventions needed to develop a supportive end of life strategy for LTC.

Conclusions

Multi-disciplinary stakeholders identified and prioritized the top interventions needed to develop a 5-point supportive end of life care strategy for LTC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02271-1.

No difference in effects of 'PACE steps to success' palliative care program for nursing home residents with and without dementia: a pre-planned subgroup analysis of the seven-country PACE trial

Background

‘PACE Steps to Success’ is a multicomponent training program aiming to integrate generalist and non-disease-specific palliative care in nursing homes. This program did not improve residents’ comfort in the last week of life, but it appeared to improve quality of care and dying in their last month of life. Because this program included only three dementia-specific elements, its effects might differ depending on the presence or stage of dementia. We aimed to investigate whether the program effects differ between residents with advanced, non-advanced, and no dementia.

Methods

Pre-planned subgroup analysis of the PACE cluster-randomized controlled trial in 78 nursing homes in seven European countries. Participants included residents who died in the previous 4 months. The nursing home staff or general practitioner assessed the presence of dementia; severity was determined using two highly-discriminatory staff-reported instruments. Using after-death questionnaires, staff assessed comfort in the last week of life (Comfort Assessment in Dying–End-of-Life in Dementia-scale; primary outcome) and quality of care and dying in the last month of life (Quality of Dying in Long-Term Care scale; secondary outcome).

Results

At baseline, we included 177 residents with advanced dementia, 126 with non-advanced dementia and 156 without dementia. Post-intervention, respectively in the control and the intervention group, we included 136 and 104 residents with advanced dementia, 167 and 110 with non-advanced dementia and 157 and 137 without dementia. We found no subgroup differences on comfort in the last week of life, comparing advanced versus without dementia (baseline-adjusted mean sub-group difference 2.1; p-value = 0.177), non-advanced versus without dementia (2.7; p = 0.092), and advanced versus non-advanced dementia (− 0.6; p = 0.698); or on quality of care and dying in the last month of life, comparing advanced and without dementia (− 0.6; p = 0.741), non-advanced and without dementia (− 1.5; p = 0.428), and advanced and non-advanced dementia (0.9; p = 0.632).

Conclusions

The lack of subgroup difference suggests that while the program did not improve comfort in dying residents with or without dementia, it appeared to equally improve quality of care and dying in the last month of life for residents with dementia (regardless of the stage) and those without dementia. A generalist and non-disease-specific palliative care program, such as PACE Steps to Success, is a useful starting point for future palliative care improvement in nursing homes, but to effectively improve residents’ comfort, this program needs further development.

Trial registration

ISRCTN, ISRCTN14741671. Registered 8 July 2015 – Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00734-1.