Separation characterized by responsibility and guilt: Family caregivers' experiences with palliative care for a close family member with severe dementia in long-term care facilities

Family Caregivers' Experiences of Long-Term Care Residents Living With Dementia During the COVID-19 Pandemic: An International Grounded Theory Study

AIMS

Caution around the COVID-19 pandemic resulted in visitation restrictions to prevent the spread of the virus among vulnerable older persons living in long-term care (LTC), which posed a threat to individual well-being and family togetherness across the globe. The purpose of this study was to explore family caregiver's experience of having a person who is living with dementia residing in a long-term care facility during the COVID-19 pandemic.

DESIGN

Qualitative descriptive study using constructivist grounded theory (GT) methodology.

METHODS

The study was carried out in five countries: the United States, Switzerland, Hong Kong (China), United Kingdom and Japan. Data were collected between June 2021 and August 2022. In-depth understanding and initial theorising about experiences and social interactions between family members, residents and long-term care staff across cultural contexts, strategies from constructive GT were used. Data were collected through 15 semi-structured, in-depth interviews with 16 family members. Analysis included individual and team-based coding, memo-writing, constant comparison and category generation.

RESULTS

Due to visit restrictions, families faced upsetting situations of exclusion. The caregiver participants experienced inequality, felt isolated and witnessed residents' despair and helplessness. Analysis revealed four subthemes to the basic social process of 'negotiating for access to maintain relational continuity': (1) Feeling excluded, isolated and upset; (2) facing depersonalising situations; (3) navigating challenging interactions; and (4) living with (post-) pandemic circumstances.

CONCLUSION

This study highlights the suffering experienced by family caregivers and their loved ones living with dementia in long-term care during COVID-19, demonstrating the key role that relationships play in family care. During similar public health crises, policies and infection prevention measures that depict family and close caregivers as visitors whose access needs to be regulated need to be altered into policies that enable a culture of partnership and inclusion acknowledging the importance of social interactions for health and well-being.

REPORTING METHOD

The COREQ checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROTOCOL REGISTRATION

Not applicable due to study design.

Evaluating the Association between the Implementation of the PoET Southwest Spread Project and Reductions in Acute Care Transfers from Long-Term Care: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch.

DESIGN

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

SETTING

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

METHODS

We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life.

RESULTS

A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62-0.87; P = .0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life.

CONCLUSIONS AND IMPLICATIONS

This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC.

Implementation of Advance Care Planning in Norway

Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.

Building a new life: a qualitative study of how family carers deal with significant changes

Background

Family carers of persons living with dementia who are residing in long term care (LTC), often experience significant changes in their roles and relationships which affects mental and physical health. Research has focused on describing the carers’ experience, but not on how they deal with these changes or their perceptions of support needs. The purpose of this study was to explore how family carers of persons living with dementia residing in LTC deal with significant changes and to understand how best to support these carers.

Methods

Eight face-to-face audio-recorded focus group interviews were conducted with 45 participants from September 2019 to January 2020, as part of a larger study aimed at guiding the adaptation of an online toolkit to support family carers of persons living with dementia residing in LTC. Applied thematic analysis was used to analyze the focus group data.

Findings/results

Carers dealt with the significant changes they experienced through the process of “building a new life” consisting of two sub-processes: a) building new relationships (with their family member, LTC staff and others outside of LTC), and b) finding space for themselves (sharing of care and finding balance). Understanding dementia, support from others (staff, family and friends), connecting with resources, and being included in care decisions helped carers build a new life.

Conclusion

The process of building a new life describes the ways that family carers deal with the life-altering changes they experienced when a family member is admitted to LTC. Carers may be supported in building their new life, by providing them with information about dementia and how to relate to staff and their family member living with dementia. The quality of care being provided and the LTC environment may also play an important role in how carers deal with the significant changes they experience.

The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review

BACKGROUND

Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia.

METHODS

In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes.

RESULTS

We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances.

CONCLUSION

Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.