Care planning needs of palliative home care clients: Development of the interRAI palliative care assessment clinical assessment protocols (CAPs)

The interRAI CHESS scale is comparable to the palliative performance scale in predicting 90-day mortality in a palliative home care population

Background

Prognostic accuracy is important throughout all stages of the illness trajectory as it has implications for the timing of important conversations and decisions around care. Physicians often tend to over-estimate prognosis and may under-recognize palliative care (PC) needs. It is therefore essential that all relevant stakeholders have as much information available to them as possible when estimating prognosis.

Aims

The current study examined whether the interRAI Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale is a good predictor of mortality in a known PC population and to see how it compares to the Palliative Performance Scale (PPS) in predicting 90-day mortality.

Methods

This retrospective cohort study used data from 2011 to 2018 on 80,261 unique individuals receiving palliative home care and assessed with both the interRAI Palliative Care instrument and the PPS. Logistic regression models were used to evaluate the relationship between the main outcome, 90-day mortality and were then replicated for a secondary outcome examining the number of nursing visits. Comparison of survival time was examined using Kaplan-Meier survival curves.

Results

The CHESS Scale was an acceptable predictor of 90-day mortality (c-statistic = 0.68; p < 0.0001) and was associated with the number of nursing days (c = 0.61; p < 0.0001) and had comparable performance to the PPS (c = 0.69; p < 0.0001). The CHESS Scale performed slightly better than the PPS in predicting 90-day mortality when combined with other interRAI PC items (c = 0.72; p < 0.0001).

Conclusion

The interRAI CHESS Scale is an additional decision-support tool available to clinicians that can be used alongside the PPS when estimating prognosis. This additional information can assist with the development of care plans, discussions, and referrals to specialist PC teams.

interRAI Pediatric Home Care (PEDS-HC) Assessment Tool: Evaluating Ontario Healthcare Workers’ Experience

High quality pediatric homecare requires comprehensive assessment of the needs, supports, and health care challenges of children with special healthcare needs and their families. There is no standardized homecare assessment system to evaluate children’s clinical needs in the home (support services, equipment, etc.) in Ontario, Canada, which contributes to inequitable homecare service allocation. In 2017, the interRAI Pediatric Home Care assessment tool (PEDS-HC) was implemented on a pilot basis in several regions of Ontario. This qualitative descriptive study explores the experiences of homecare coordinators using the PEDS-HC, seeking to understand the utility and feasibility of this tool through focus group discussion. Four major themes were identified including: the benefits of the tool; areas for modification; challenges to use; and Clinical Assessment Protocols to develop. These themes can guide modifications to the tool to improve utility and improve pediatric home care services. The PEDS-HC is an effective tool to assess children needing homecare in a standardized and comprehensive manner. Use of the tool can improve the quality of homecare services by ensuring equity in service provision and facilitate early identification of clinical issues to prevent unexpected health deteriorations.

The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review

BACKGROUND

Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents.

METHODS

The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature.

RESULTS

Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care CONCLUSIONS: Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology.

REGISTRATION

PROSPERO registration number CRD42020171323.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

Prognosis does not change the landscape: palliative home care clients experience high rates of pain and nausea, regardless of prognosis

BACKGROUND

Most individuals who typically receive palliative care (PC) tend to have cancer and a relatively short prognosis (< 6 months). People with other life-limiting illnesses can also benefit from a palliative care approach. However, little is known about those who receive palliative home care in Ontario, Canada's largest province. To address this gap, the goal of this project was to understand the needs, symptoms and potential differences between those with a shorter (< 6 months) and longer prognosis (6+ months) for individuals receiving PC in the community.

METHODS

A cross-sectional analysis was conducted using interRAI Palliative Care (interRAI PC) assessment data collected between 2011 and 2018. Individuals with a shorter prognosis (< 6 months; n = 48,019 or 64.1%) were compared to those with a longer prognosis (6+ months; n = 26,945) across several clinical symptoms. The standardized difference (stdiff), between proportions, was calculated to identify statistically meaningful differences between those with a shorter and longer prognosis. Values of the stdiff of 0.2 or higher (absolute value) indicated a statistically significant difference.

RESULTS

Overall, cancer was the most prevalent diagnosis (83.2%). Those with a shorter prognosis were significantly more likely to experience fatigue (75.3% vs. 59.5%; stdiff = 0.34) and shortness of breath at rest (22.1% vs. 13.4%; stdiff = 0.23). However, the two groups were similar in terms of severe pain (73.5% vs. 66.5%; stdiff = - 0.15), depressive symptoms (13.2% vs. 10.7%; stdiff = 0.08) and nausea (35.7% vs. 29.4%; stdiff = 0.13).

CONCLUSIONS

These results highlight the importance of earlier identification of individuals who could benefit from a palliative approach to their care as individuals with a longer prognosis also experience high rates of symptoms such as pain and nausea. Providing PC earlier in the illness trajectory has the potential to improve an individual's overall quality of life throughout the duration of their illness.

Psychometric Properties, Feasibility, and Acceptability of the Self-Reported interRAI Check-Up Assessment

OBJECTIVES

To assess the feasibility, acceptability, and psychometric properties of the self-report version of the interRAI Check-Up (CUSR).

DESIGN

Cross-sectional study of participant ratings of item content and difficulty completing the CUSR. Participants were also randomly assigned to complete the assessment by themselves or with help from a lay interviewer.

SETTINGS AND PARTICIPANTS

A total of 184 older adults from diverse backgrounds, served by 6 Canadian organizations in Ontario and Nova Scotia were recruited. Settings ranged from retirement communities for healthy older adults to assisted living facilities.

MEASURES/METHODS

Time to complete the interRAI CUSR was tracked automatically. Participants self-reported on what items they wanted to have modified, added, or deleted. The also rated whether items were embarrassing or difficult to complete. Psychometric properties were examined between the 2 approaches to completion and were benchmarked against existing reports on psychometric properties of clinician-led home care assessments.

RESULTS

The interRAI CUSR takes about 28 minutes to complete with both self-administered and lay interviewer approaches. The convergent validity and reliability of CUSR is comparable to those of clinician-based assessments like the Resident Assessment Instrument-Home Care. Most participants had no difficulty completing the assessment, and none rated the task as very difficult. Poor self-rated health and difficulty with phone use were predictive of any difficult in completing the assessment in a multivariate logistic regression. Most participants reported that CUSR adequately described their health needs, but arthritis, hypertension, and mental health issues were identified as items to be added by participants.

CONCLUSIONS AND IMPLICATIONS

The CUSR is an appropriate, feasible assessment system with good psychometric properties for use with general populations, including primary care, community services, and patient-reported outcome measurement studies. Interoperability with other interRAI assessments makes it an ideal system to use to obtain a longitudinal view of the person's needs over time.

A Cross-Sectoral Comparison of Prevalence and Predictors of Symptoms of Depression Over Time Among Older Adults in Ontario, Canada

OBJECTIVES

Late-life depression, a common mental health issue, poses a significant burden of illness globally. We investigated factors associated with symptoms of depression among older adults across 3 health sectors in Ontario, Canada.

METHOD

Electronic health assessment data on older adults aged 60 years+ in home care (HC; N = 359 217), long-term care (LTC; N = 125 496), and palliative care (PC; N = 29 934) were examined. Change in symptoms of depression, measured using the interRAI Depression Rating Scale (DRS), over time was examined, including predictors of the development of depression.

RESULTS

At baseline, symptoms of depression were observed in 19.1% (HC), 24.2% (LTC), and 11.9% (PC). This increased to 20.6% (HC), 33.8% (LTC), and 13.2% (PC) at follow-up. For most older adults, DRS scores remained the same across sectors over time. Three independent variables emerged consistently across sectors as the main risk and protective factors for symptoms of depression.

CONCLUSION

Although variations in the risk and protective factors for late-life depression were demonstrated across each sector, some commonalities emerged including unmanaged pain, symptoms of depression at baseline, social connectedness, and activity.

Nurses' needs when collaborating with other healthcare professionals in palliative dementia care

Adequate interprofessional collaboration is essential to provide high quality palliative dementia care across different settings. Within interprofessional collaboration, nurses are the frontline healthcare professionals (HCPs), who interact closely with people with dementia, their loved ones, and other HCPs. A survey was conducted to explore the needs of nurses regarding interprofessional collaboration in home care (HC) organisations, nursing homes (NHs) and during NH admissions. The survey identified the perceived quality of and preferred needs regarding interprofessional collaboration. In total, 384 participants (53.9% home care nurses) completed the survey. The most frequently reported collaboration needs in HC organisations and NH were optimal communication content e.g. information transfer and short communication lines (being able to easily contact other disciplines), and coordination e.g. one contact person, and clear task division and responsibilities). During NH admissions, it was important to create transparency about agreements concerning end-of-life wishes, optimize nurse-to-nurse handover during NH admissions (through performing visits prior to admissions, and receiving practical information on how to guide relatives), and improve coordination (e.g. one contact person). In conclusion, the key collaboration needs were organising central coordination, establishing optimal communication, and creating transparency on end-of-life care agreements.

Cross-Sectional Nutrition Profile of Palliative Home Care Clients in Ontario and Performance of the interRAI Palliative Care Nutrition Clinical Assessment Protocol

BACKGROUND

The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP).

METHODS

This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance.

RESULTS

Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP.

CONCLUSIONS

Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population.

Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis

CONTEXT

Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment.

OBJECTIVE

The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings.

METHODS

This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma.

RESULTS

Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care.

CONCLUSION

Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.

Hospice Utilization Among Residents in Long-Term Care Facilities

BACKGROUND

Hospice care can improve quality of life for persons nearing end of life, yet little is known about utilization of hospice care among persons residing in long-term care facilities (LTCFs). Given the increasing number of deaths that occur in LTCFs, it is important to examine hospice care practices in LTCFs.

AIM

The aim of the cross-sectional study was to describe residents who received hospice care in LTCFs and explore factors that can predict hospice use in LTCFs across Canada. This study included 185 715 residents aged 19 years or older in LTCFs in Canada in 2015.

RESULTS

Of all residents, 2.7% (n = 4973) received hospice care and 6.8% (n = 12 684) were profiled as having an end-stage disease. Among those who received hospice care, most were noted as end stage (89.5%) and had severe physical impairment (Activities of Daily Living Hierarchy Scale ≥ 5, 74.3%), mild-to-severe pain (Pain Scale ≥ 1, 76.0%), and moderate-to-severe health instability (Changes in Health, End-Stage Disease, Signs, and Symptoms Scale ≥3, 82.9%). Residents who received hospice care were in more severe and complex clinical conditions than those who did not receive hospice care.

CONCLUSION

Only a small proportion of residents in LTCFs received hospice care. Further investigation of standardized assessment of terminal status is needed as accuracy of end-stage diagnosis continues to be challenging and criteria for hospice eligibility are narrow. Special attention should be paid to improve access to hospice care among residents with dementia or other progressive chronic diseases with severe and complex clinical needs.

Hospice use and one-year survivorship of residents in long-term care facilities in Canada: a cohort study

Background

Hospice care is designed for persons in the final phase of a terminal illness. However, hospice care is not used appropriately. Some persons who do not meet the hospice eligibility receive hospice care, while many persons who may have benefitted from hospice care do not receive it. This study aimed to examine the characteristics of, and one-year survivorship among, residents who received hospice care versus those who did not in long-term care facilities (LTCFs) in Canada.

Methods

This retrospective cohort study used linked health administrative data from the Canadian Continuing Reporting System (CCRS) and the Discharge Abstract Database (DAD). All persons who resided in a LTCF and who had a Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0) assessment in the CCRS database between Jan. 1st, 2015 and Dec 31st, 2015 were included in this study (N = 185,715). Death records were linked up to Dec 31th, 2016. Univariate, bivariate and multivariate analyses were performed.

Results

The reported hospice care rate in LTCFs is critically low (less than 3%), despite one in five residents dying within 3 months of the assessment. Residents who received hospice care and died within 1 year were found to have more severe and complex health conditions than other residents. Compared to those who did not receive hospice care but died within 1 year, residents who received hospice care and were alive 1 year following the assessment were younger (a mean age of 79.4 [+ 13.5] years vs. 86.5 [+ 9.2] years), more likely to live in an urban LTCF (93.2% vs. 82.6%), had a higher percentage of having a diagnosis of cancer (50.7% vs. 12.9%), had a lower percentage of having a diagnosis of dementia (30.2% vs. 54.5%), and exhibited more severe acute clinical conditions.

Conclusions

The actual use of hospice care among LTCF residents is very poor in Canada. Several factors emerged as potential barriers to hospice use in the LTCF population including ageism, rurality, and a diagnosis of dementia. Improved understanding of hospice use and one-year survivorship may help LTCFs administrators, hospice care providers, and policy makers to improve hospice accessibility in this target group.

The incidence and prevalence of delirium across palliative care settings: A systematic review

BACKGROUND

Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed.

AIM

Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings.

DESIGN

This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment.

DATA SOURCES

Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included.

RESULTS

Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used.

CONCLUSION

Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.

HPNA 2019-2022 Research Agenda: Development and Rationale

Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.

Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative

AIM

This paper reports on a quality-improvement project to develop nursing documentation that reflects holistic care within a specialist palliative centre.

BACKGROUND

The World Health Organization definition of palliative care includes impeccable assessment and management of pain and other symptoms. However, existing nursing documentation focuses mainly on the management of physical symptoms, with other aspects of nursing less frequently documented.

METHODS

Supported by a project team and expert panel, cycles of review, action and reflection were used to develop a new palliative nursing documentation. The project was divided into three phases: audits of existing nursing documentation, development of a new palliative nursing care document and audit tool, and pilot implementation and audit of the new nursing documentation.

RESULTS

The new palliative nursing care document demonstrated a higher level of compliance in relation to nursing assessments and a more concise, accurate and comprehensive approach to documenting holistic nursing care and recording of patients' perspective.

CONCLUSIONS

This project has enabled the consistent documentation of holistic nursing care and patients' perspectives; however, continuous education is necessary in order to sustain positive results and ensure that documentation does not become a 'tick box' exercise. Organisational support is required in order to improve documentation systems.

A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care

CONTEXT

Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps.

OBJECTIVES

To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes.

METHODS

A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent.

RESULTS

Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature.

CONCLUSION

Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.

Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities

BACKGROUND

To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial.

OBJECTIVE

This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS).

DESIGN

A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong.

SETTING/SUBJECTS

A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation.

MEASUREMENTS

The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression.

RESULTS

The IRD scale was a strong predictor of mortality in both Sample 1 (HR_sample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HR_sample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively.

CONCLUSIONS

The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.

Instruments for the functional assessment of elderly persons in palliative care: an integrative review

Abstract Objective: to identify validated instruments that can be used for the functional assessment of elderly persons in Palliative Care. Method: an integrative review focused on identifying instruments for the functional assessment of elderly persons in palliative care was carried out by searching publications in periodicals indexed in seven electronic databases. Descriptors, keywords and Boolean operators were used for a cross-database search in November 2017. A total of 357 abstracts were identified, from which 53 articles were selected for reading, of which 21 met the inclusion criteria. Results: this strategy allowed the identification of eight scales and one test for the functional assessment of elderly persons in palliative care. Conclusion: eight scales and a functional test which also provide guidelines for improving the quality of life of elderly people in palliative care were identified, demonstrating that it is practically impossible to disassociate physical functional performance from social and psychological aspects.

Adverse Events in Home Care: Identifying and Responding with interRAI Scales and Clinical Assessment Protocols

Outcomes of adverse events in home care are varied and multifactorial. This study tested a framework combining two health measures to identify home care recipients at higher risk of long-term care placement or death within one year. Both measures come from the Resident Assessment Instrument-Home Care (RAI-HC), a standardized comprehensive clinical assessment. Persons scoring high in the Method for Assigning Priority Levels (MAPLe) algorithm and Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale were at the greatest risk of placement or death and more than twice as likely to experience either outcome earlier than others. The target group was more likely to trigger mood, social relationship, and caregiver distress issues, suggesting mental health and psychosocial interventions might help in addition to medical care and/or personal support services. Home care agencies can use this framework to identify home care patients who may require a more intensive care coordinator approach.

The amyotrophic lateral sclerosis supportive care needs assessment instrument: Development and psychometric evaluation

OBJECTIVE

The aim of the study is to develop an amyotrophic lateral sclerosis supportive care needs (ALSSCN) instrument based on Fitch's Supportive Care Needs Framework and to test its psychometric properties.

METHOD

This study consists of three parts: (1) item generation from the literature review and qualitative interview; (2) content validation; and (3) psychometric evaluation of the instrument. Participants who were diagnosed with ALS (n = 139) were recruited from two ALS clinics in Seoul, Korea, and Busan, Korea for the psychometric testing.ResultThe ALSSCN consisted of 37 items with seven domains: physical, psychological, emotional, spiritual, social, informational, and practical needs. The Cronbach's alpha of each domain ranged from 0.61 (social needs) to 0.90 (emotional needs). The intra-class correlation coefficient for test-retest was 0.89, indicating good test-retest reliability. The overall ALSSCN was significantly negatively correlated with the quality of life, which supported convergent validity. Confirmatory factor analysis of the ALSSCN supported a seven-factor model.Significance of resultsThe ALSSCN has acceptable internal consistency, stability, and content and construct validity in a Korean ALS population. ALSSCN is a psychometrically sound measure and can be adopted by healthcare professionals, researchers, and administrators to comprehensively assess the perceived supportive care needs of patients with ALS.

Does using the interRAI Palliative Care instrument reduce the needs and symptoms of nursing home residents receiving palliative care?

Objective:

This study aimed to evaluate whether using the interRAI Palliative Care instrument (the interRAI PC) in nursing homes is associated with reduced needs and symptoms in residents nearing the end of their lives.

Method:

A quasi-experimental pretest–posttest study using the Palliative care Outcome Scale (POS) was conducted to compare the needs and symptoms of residents nearing the end of their lives in the control and intervention nursing homes. Care professionals at the intervention nursing homes filled out the interRAI PC over the course of a year for all residents aged 65 years and older who were nearing the end of their lives. This intervention was not implemented in the control nursing homes.

Results:

At baseline, POS scores in the intervention nursing homes were lower (more favorable) than in the control nursing homes on the items “pain”, “other symptoms”, “family anxiety”, and the total POS score. Posttest POS scores for “wasted time” were higher (less favorable) than pretest scores in the intervention nursing homes. In the intervention nursing homes where care professionals did not have prior experience with the interRAI Long-Term Care Facilities (LTCF) assessment instrument (n = 8/15), total POS scores were lower (more favorable) at posttest.

Significance of results:

One year after introducing the interRAI PC, no reduction in residents' needs and symptoms were detected in the intervention nursing homes. However, reductions in needs and symptoms were found in the subgroup of intervention nursing homes without prior experience with the interRAI LTCF instrument. This may suggest that the use of an interRAI instrument other than the interRAI PC specifically can improve care. Future research should aim at replicating this research with a long-term design in order to evaluate the effect of integrating the use of the interRAI PC in the day-to-day practices at nursing homes.

The wish to die among palliative home care clients in Ontario, Canada: A cross-sectional study

Background

In the pursuit to provide the highest quality of person centered palliative care, client preferences, needs, and wishes surrounding end of life should be used to inform the plan of care. During a clinical assessment for care services, clients may voluntarily express a ‘wish to die’ either directly to the clinician or it may be indirectly reported second-hand to the clinician through an informal caregiver or family member. This is the first study using data gathered from the interRAI Palliative Care Assessment instrument (interRAI PC) to examine socio-demographic, clinical, and psycho-social factors of palliative home care clients with the voluntary expression of a ‘wish to die now’. Factors associated with the risk for depression within this group were also identified. Awareness and understanding of clients who express the ‘wish to die’ is needed to better tailor a person-centered approach to end-of-life care.

Methods

This cross-sectional study included assessment records gathered from 4,840 palliative home care clients collected as part of pilot implementation of the interRAI PC assessment instrument in Ontario, Canada from 2006 through 2011.

Results

During the clinical assessment, 308 palliative home care clients (6.7 %) had voluntarily expressed a ‘wish to die now’. Independent factors emerging from multivariate logistic regression analyses predicting the expression of a ‘wish to die’ included not being married/widowed, a shorter estimated prognosis, depressive symptoms, functional impairment, too much sleep (excessive amount), feeling completion regarding financial/legal matters, and struggling with the meaning of life. Among persons who expressed a ‘wish to die now’, those who exhibited depressive symptoms (23.8 %, n = 64) were also more likely to exhibit cognitive impairment, have decline in cognition in the last 90 days, exhibit weight loss, have informal caregivers exhibiting distress, ‘not have a consistent positive outlook on life’ and report ‘struggling with the meaning of life’.

Conclusion

When clients voluntary express a wish to die clinicians should take notice and initiate follow-up to better understand the context of this meaning for the individual. Clients who expressed a ‘wish to die’ did not all experience pain, depression, and psychological distress suggesting an individualized approach to care management be taken.

A Cross-Sectional Examination of the Association Between Dyspnea and Distress as Experienced by Palliative Home Care Clients and Their Informal Caregivers

This study examined the association between dyspnea and distress as experienced by both palliative home care clients and their informal caregivers as a unit of care. Cross-sectional analysis was conducted using the interRAI Palliative Care Assessment database. Responses from 6,655 individual palliative home care clients across six regional jurisdictions in Ontario, Canada were included. This study found that clients experiencing dyspnea were more likely to show overall signs of distress; report one or more signs of self-reported distress; and be at risk for depression when compared to clients who do not experience dyspnea. Caregivers of clients experiencing dyspnea were more likely to exhibit distress than caregivers of clients not reporting dyspnea. When indicators of caregiver distress and client distress were combined, 53% of the caregiver-client units exhibited distress. Social work practitioners should include a focus on distress within the care unit as a priority when care planning to meet the needs of persons nearing the end of life. Members of the care team should consider available treatment and management options tailored to meet both the client and their informal caregiver's needs.

Correlates and Predictors of Changes in Dyspnea Symptoms Over Time Among Community-Dwelling Palliative Home Care Clients

CONTEXT

Dyspnea is a frequently reported and highly distressing symptom for persons nearing end of life, affecting the quality of living and dying.

OBJECTIVES

This study described health and clinical characteristics of persons experiencing dyspnea who receive palliative home care services and identified factors affecting change in dyspnea over time.

METHODS

Anonymized assessments (N = 6655 baseline; 959 follow-up) from the interRAI palliative care assessment instrument (interRAI PC) were collected during pilot implementation (2006-2011). Triggering of the interRAI PC dyspnea clinical assessment protocol was used to indicate presence of dyspnea. Bivariate and logistic regression analyses described risk and protective factors for developing new dyspnea and for recovery from dyspnea at follow-up.

RESULTS

At baseline, 44.9% of persons exhibited dyspnea. Dyspnea was more prevalent among older adults, males, persons with shortened prognoses, and persons without cancer. Persons with dyspnea were more likely to experience functional impairment, moderate cognitive impairment, fatigue, weight loss, and urinary incontinence. Among persons with dyspnea at baseline, 31.5% recovered from dyspnea at follow-up. In contrast, 31% of persons without dyspnea at baseline reported new dyspnea at follow-up. Risk factors for developing new dyspnea included smoking, fatigue, and receiving oxygen therapy.

CONCLUSION

Results highlight that dyspnea is not inevitable as persons progress toward death. Accordingly, dyspnea should be identified and prioritized during the care planning process. Integrated approaches using the interRAI PC dyspnea clinical assessment protocol may assist clinicians to make informed decisions addressing dyspnea at the person-level and thereby improve quality of life at the end of life.