1
|
Roberts RL, Milani C, Webber C, Bush SH, Boese K, Simon JE, Downar J, Arya A, Tanuseputro P, Isenberg SR. Enablers and Barriers for End-of-Life Symptom Management Medications in Long-Term Care Homes: A Qualitative Study. J Am Med Dir Assoc 2024; 25:105076. [PMID: 38857683 DOI: 10.1016/j.jamda.2024.105076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/07/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVES Long-term care (LTC) homes provide personal and medical care 24/7 to individuals unable to live at home due to illness or disability and are often the final place of care and death for their residents. Therefore, LTC homes are tasked with providing quality end-of-life care, often requiring injectable symptom management medications to relieve distressing symptoms (eg, pain). In this study, we aimed to understand the enablers and barriers to prescribing and administering end-of-life symptom management medications in LTC homes. DESIGN Qualitative study. SETTING AND PARTICIPANTS From February 2021 to December 2022, we conducted virtual semi-structured interviews with health care providers (physicians and nurses) who worked in Ontario LTC homes and family caregivers of residents who died in LTC. METHODS We analyzed interview transcripts using thematic analysis. RESULTS We identified 4 themes related to factors that may impact the prescribing and administering of medications for end-of-life symptom management: (1) identifying the end-of-life period and symptoms, (2) communication among health care providers and between health care providers and family caregivers, (3) health care provider competency with end-of-life medications, and (4) resources for LTC staff to support medication prescribing and administrating. CONCLUSIONS AND IMPLICATIONS In LTC, there are distinct challenges in the prescribing and administrating of end-of-life symptom management medications. Our findings can be used to inform interventions aimed at improving end-of-life care for LTC residents. However, these interventions require buy-in and investment from the provincial government and the LTC sector.
Collapse
Affiliation(s)
| | | | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jessica E Simon
- Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit Arya
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Kensington Research Institute, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; School of Epidemiology and Public Health, Faculty of Medicine, Ottawa, Ontario, Canada
| |
Collapse
|
2
|
de Sola-Smith K, Gilissen J, van der Steen JT, Mayan I, Van den Block L, Ritchie CS, Hunt LJ. Palliative Care in Early Dementia. J Pain Symptom Manage 2024:S0885-3924(24)00798-X. [PMID: 38848792 DOI: 10.1016/j.jpainsymman.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/14/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Palliative care is recommended for all people with dementia from diagnosis through end-of-life. However, palliative care needs and effective elements of palliative care are not well-defined for the earlier stages of dementia. OBJECTIVE To systematically map current research on palliative care early in the disease trajectory of dementia. DESIGN Scoping review of scientific literature. DATA SOURCES PubMed, CINAHL, EMBASE, Cochrane, PsycINFO, Web of Science. REVIEW METHODS We included studies published in English over the last decade (through March 2022) that focused on palliative care in early stages of dementia and targeted outcomes in palliative care domains. Two authors independently screened abstracts and full texts and scored the quality of included studies using tools by the Joanna Briggs Institute. RESULTS Among the 77 papers reviewed, few addressed early stages of dementia specifically. We found that: 1) While "early" palliative care was not well-defined in the literature, evidence indicated that palliative care needs were present at or before diagnosis and across the trajectory. Notable opportunities for palliative care arise at 'tipping points' (i.e., when symptoms, functional status, or caregiving needs change). 2) Palliative care needs in early dementia include advocacy for goal-aligned care in the future, reassurance against the threat of negligence and abandonment by caregivers, planning for future scenarios of care (practical, individual, and relational needs), and establishing of long-term relationships with providers entrusted for care later in disease. 3) Elements of effective palliative care in early dementia could include dementia-specific ACP and goals of care discussions, navigation for building a network of support, provision of tools and resources for family, tailored care and knowledge of the person, and well-prepared dementia-care providers. The scarcity of palliative care studies aimed at early disease indicates a gap in the evidence in dementia care. CONCLUSION The literature on palliative care in early dementia is sparse. Future studies should focus on assessment tools for optimizing timing of palliative care in early dementia, gaining better understanding of patient and family needs during early phases of disease, and providing training for providers and families in long-term relationships and communication around goals of care and future planning.
Collapse
Affiliation(s)
- Karen de Sola-Smith
- Department of Geriatrics (K.d.S.), Palliative and Extended Care, Veterans Affairs Medical Center, San Francisco, California, USA; Department of Physiological Nursing (K.d.S., L.J.H.), University of California San Francisco, California, USA.
| | - Joni Gilissen
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Department of Family Medicine and Chronic Care (J.G., L.V.B), Vrije Universiteit Brussel (VUB) and Department of Public Health and Primary Care, End-of-Life Care Research Group, Universiteit Gent, Brussels, Belgium
| | - Jenny T van der Steen
- Department of Primary and Community Care and Radboudumc Alzheimer Center (J.T.S.), Radboud university medical center, Nijmegen, The Netherlands; Department of Public Health and Primary Care (J.T.S.), Leiden University Medical Center, Leiden, The Netherlands
| | - Inbal Mayan
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care (J.G., L.V.B), Vrije Universiteit Brussel (VUB) and Department of Public Health and Primary Care, End-of-Life Care Research Group, Universiteit Gent, Brussels, Belgium
| | - Christine S Ritchie
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Division of Palliative Care and Geriatric Medicine and the Mongan Institute for Aging and Serious Illness (CASI) (C.S.R.), Massachusetts General Hospital (MGH), Boston, Massachusetts, USA; Harvard Medical School (C.S.R.), Harvard University, Boston, Massachusetts, USA
| | - Lauren J Hunt
- Global Brain Health Institute (GBHI) (J.G., I.M., C.S.R., L.J.H.), University of California San Francisco, California, USA; Department of Physiological Nursing (K.d.S., L.J.H.), University of California San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies (L.J.H.), University of California San Francisco, California, USA
| |
Collapse
|
3
|
Nishimura M, Harrison Dening K, Sampson EL, Vidal EIDO, Nakanishi M, Davies N, Abreu W, Kaasalainen S, Eisenmann Y, Dempsey L, Moore KJ, Bolt SR, Meijers JMM, Dekker NL, Miyashita M, Nakayama T, van der Steen JT. A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study. Palliat Med 2024; 38:457-470. [PMID: 38634232 PMCID: PMC11025301 DOI: 10.1177/02692163241234579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life. AIM To develop a multidimensional international palliative care goals model in dementia for use in practice. DESIGN International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified. SETTING/PARTICIPANTS Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study. RESULTS Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves. CONCLUSION A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.
Collapse
Affiliation(s)
- Mayumi Nishimura
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto Prefecture, Japan
| | | | - Elizabeth L Sampson
- Royal London Hospital and Centre for Psychiatry and Mental health, East London NHS Foundation Trust, London, UK
- Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | | | - Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Wilson Abreu
- Center for Health Technology and Ser- vices Research, University of Porto (ESEP/CINTESIS), Porto, Portugal
| | | | - Yvonne Eisenmann
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Laura Dempsey
- Department of Nursing and Healthcare, Technological University of the Shannon: Midlands Midwest, Athlone, Ireland
| | - Kirsten J Moore
- National Ageing Research Institute, Parkville, VIC, Australia
- Medicine-Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Sascha R Bolt
- Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, North Brabant, The Netherlands
| | - Judith MM Meijers
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Limburg, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
- Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, South Holland, The Netherlands
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto Prefecture, Japan
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, South Holland, The Netherlands
- Department of Primary and Community Care, Radboud University, Nijmegen, The Netherlands
- Cicely Saunders Institute, King’s College London, UK
| |
Collapse
|
4
|
Waddington C, Flanagan K, Clements H, Harding E, van der Byl Williams M, Walton J, Crutch S, Stott J. Grief and loss in people living with dementia: a review and metasynthesis of qualitative studies. Aging Ment Health 2024; 28:408-421. [PMID: 37970882 DOI: 10.1080/13607863.2023.2280925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This review seeks to synthesise qualitative studies that focus on the experience of grief and loss in people living with dementia. METHODS Included studies were quality appraised, synthesised and analysed using inductive thematic analysis. RESULTS 19 studies were selected for inclusion in the final review and metasynthesis, including 486 participants (115 participants living with dementia, 152 family carers, 219 professionals). Five key dimensions of grief in people living with dementia were identified during the analysis process: grieving for the person I used to be, grieving for how others see me, grieving for the person I will become, grieving for those who have died and what helps me with my grief. CONCLUSION It is evident that people living with dementia can experience grief related to a range of previous, current and anticipated losses. Many of the studies included in this review did not directly include people living with dementia in their research and did not ask participants directly about their experience of grief and loss. As grief is a highly personal and individual experience, further research addressing the experience of grief that directly includes participants living with dementia is required, in order to improve awareness of grief-related needs and to develop and deliver support to meet these needs.
Collapse
Affiliation(s)
- Claire Waddington
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Katie Flanagan
- Centre for Ageing Population Studies, Primary Care and Population Health, University College London, London, UK
| | - Henry Clements
- Clinical Education and Health Psychology, University College London, London, UK
| | - Emma Harding
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | | | - Jill Walton
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Sebastian Crutch
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Joshua Stott
- ADAPT Lab, Clinical Education and Health Psychology, University College London, London, UK
| |
Collapse
|
5
|
Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol. BMC Palliat Care 2022; 21:202. [PMID: 36419147 PMCID: PMC9684772 DOI: 10.1186/s12904-022-01097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia. METHODS/DESIGN This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners. DISCUSSION This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.
Collapse
|
6
|
Nishimura M, Dening KH, Sampson EL, de Oliveira Vidal EI, de Abreu WC, Kaasalainen S, Eisenmann Y, Dempsey L, Moore KJ, Davies N, Bolt SR, Meijers JMM, Dekker NL, Miyashita M, Nakanishi M, Nakayama T, van der Steen JT. Cross-cultural conceptualization of a good end of life with dementia: a qualitative study. Palliat Care 2022; 21:106. [PMID: 35676673 PMCID: PMC9175529 DOI: 10.1186/s12904-022-00982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/19/2022] [Indexed: 09/25/2023] Open
Abstract
Background Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models. Methods We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies. Results Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes. Conclusions The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model. Trial registration The Graduate School and Faculty of Medicine Kyoto University (R1924–1). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00982-9.
Collapse
Affiliation(s)
- Mayumi Nishimura
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan.
| | | | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK
| | - Edison Iglesias de Oliveira Vidal
- Botucatu Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, Botucatu, SP, 18618-687, Brazil
| | - Wilson Correia de Abreu
- Center for Health Technology and Services Research, University of Porto (ESEP/CINTESIS), R. Dr. Plácido da Costa, 4200-450, Porto, Portugal
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Yvonne Eisenmann
- Department of Palliative Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Laura Dempsey
- Department of Nursing and Healthcare, Technological University of the Shannon: Midlands Midwest, Dublin Road, Athlone, Co Westmeath, N37 HD68, Ireland
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,National Ageing Research Institute Inc., Royal Melbourne Hospital, Royal Park Campus, Gate 4, Building 8, 34-54 Poplar Rd, Parkville, VIC, 3052, Australia
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,Research Department of Primary Care and Population Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Sascha R Bolt
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Judith M M Meijers
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands.,Zuyderland Care, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162, BG, Sittard-Geleen, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Pieter de la Court Wassenaarseweg 52, 2333, AK, Leiden, The Netherlands
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333, ZD, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
7
|
Harper AE, Terhorst L, Moscirella M, Turner RL, Piersol CV, Leland NE. The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review. DEMENTIA 2021; 20:2746-2765. [PMID: 33899537 DOI: 10.1177/14713012211012606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Alexandra E Harper
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Marybeth Moscirella
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Rose L Turner
- Health Sciences Library System, 499478University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine V Piersol
- Department of Occupational Therapy, Jefferson College of Rehabilitation Sciences, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
8
|
Kaasalainen S, Mccleary L, Vellani S, Pereira J. Improving End-of-Life Care for People with Dementia in LTC Homes During the COVID-19 Pandemic and Beyond. Can Geriatr J 2021; 24:164-169. [PMID: 34484498 PMCID: PMC8390320 DOI: 10.5770/cgj.24.493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
COVID-19 pandemic has resulted in a significant increase in deaths in long-term care homes (LTCH). People with dementia living in LTCHs represent one of the most frail and marginalized populations in Canada. The surge of COVID-19 cases in LTCHs and rationing of health-care resources during the pandemic have amplified the pre-existing need for improvements in palliative and end-of-life care in LTCHs. This position statement, created by a task force commissioned by the Alzheimer Society of Canada, provides recommendations for a multipronged coordinated approach to improving palliative and end-of-life care of people with dementia living in LTCHs during the COVID-19 pandemic and beyond.
Collapse
Affiliation(s)
| | - Lynn Mccleary
- Faculty of Applied Health Sciences, Nursing, Brock University, St. Catharines, ON
| | - Shirin Vellani
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON
| | - Jose Pereira
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, ON.,Pallium Canada, Ottawa, ON
| |
Collapse
|
9
|
Durepos P, Akhtar-Danesh N, Sussman T, Ploeg J, Boerner K, Kaasalainen S. Evaluation of the Caring Ahead: Preparing for End-of-Life With Dementia Questionnaire. J Am Med Dir Assoc 2021; 22:2108-2114.e4. [PMID: 34302752 DOI: 10.1016/j.jamda.2021.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/03/2021] [Accepted: 06/27/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Family caregivers of persons with dementia rarely feel prepared for end of life although preparedness predicts outcomes in bereavement. The Caring Ahead: Preparing for End-of-Life With Dementia questionnaire was developed to measure family caregiver death preparedness. The aim of this study was to evaluate questionnaire psychometrics and refine the Caring Ahead questionnaire. DESIGN A quantitative cross-sectional reliability study design was used to evaluate the questionnaire. SETTING/PARTICIPANTS Data were collected by mail from 134 English-speaking family caregivers of persons with dementia recruited from more than 50 congregate living facilities in Canada. Thirty-two participants completed a test-retest. METHODS Analysis of psychometrics included exploratory factor analysis, calculation of correlation with a single-global preparedness item, Cronbach alpha, intraclass correlation coefficient (ICC) over time. RESULTS A 4-factor model with 20 items emerged through exploratory factor analysis with principal factors extraction and promax rotation. The revised questionnaire includes 4 factor subscales: Actions (7 items), Dementia Knowledge (5 items), Communication (4 items), and Emotions and Support Needs (4 items). Evidence was demonstrated for concurrent validity (0.44-0.55, P < .001), internal consistency (alpha > 0.7), and reliability (ICCs > 0.7). Lower levels of preparedness were reported for "knowing what the dying process with dementia may be like" and "discussing end-of-life care and preferences with health care providers." CONCLUSIONS AND IMPLICATIONS Preliminary evidence for validity and reliability of the refined 20-item Caring Ahead questionnaire suggests the questionnaire may be useful to clinicians and researchers seeking to assess caregivers' feelings of preparedness, identify specific areas for intervention, and evaluate the effectiveness of caregiver interventions. Additional testing is needed to evaluate predictive validity.
Collapse
Affiliation(s)
- Pamela Durepos
- Faculty of Nursing, University of New Brunswick, Fredericton, New Brunswick, Canada.
| | - Noori Akhtar-Danesh
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Tamara Sussman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Jenny Ploeg
- Director of Aging and Community Health Research Unit [ACHRU], Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Kathrin Boerner
- Department of Gerontology, McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA
| | - Sharon Kaasalainen
- Gladys Sharpe Chair in Nursing, Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
10
|
Schüttengruber G, Halfens RJG, Lohrmann C. Care dependency of patients and residents at the end of life: A secondary data analysis of data from a cross-sectional study in hospitals and geriatric institutions. J Clin Nurs 2021; 31:657-668. [PMID: 34151486 PMCID: PMC9291881 DOI: 10.1111/jocn.15925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 05/03/2021] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
Aims and objectives The holistic care dependency concept can be applied to gain comprehensive insights into individuals’ care needs in the end‐of‐life (EoL) phase. This study was carried out to measure and characterise the “care dependency” phenomenon in this phase and to obtain deeper knowledge about this phenomenon. Background The end of a human life is often characterised by a physical decline, often implying that a high amount of care is needed. Non‐malignant diseases can develop unpredictably; therefore, it is difficult to detect the onset of the EoL phase. Design Data were collected in a cross‐sectional multicentre study, using the Austrian Nursing Quality Measurement 2.0. Methods Descriptive and multivariate statistical methods were used. Care dependency was measured with the Care Dependency Scale (CDS). The study follows the STROBE guideline. Results Ten per cent (n = 389) of the sample (N = 3589) were allocated to “a pathway for management of patients at the end of life.” The patients and residents in the EoL phase are significantly older and more often diagnosed with dementia, and circulatory system and musculoskeletal system diseases. Of these patients, 60% were care dependent completely or to a great extent. Dementia and age represent main influencing factors that affect the degree of care dependency at the end of life. Conclusion Our results show that the “typical” EoL patient or resident is female, old and affected by dementia and/or circulatory system diseases. Dementia and age were identified as main factors that contribute to very high care dependency. Relevance to clinical practice The measurement of care dependency may support the identification of special care needs in the EoL phase. Gaining deeper knowledge about the care dependency phenomenon can also help healthcare staff better understand the needs of patients with non‐malignant conditions in their last phase of life.
Collapse
Affiliation(s)
| | - Ruud J G Halfens
- Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Christa Lohrmann
- Institute of Nursing Science, Medical University of Graz, Graz, Austria
| |
Collapse
|
11
|
Davies N, De Souza T, Rait G, Meehan J, Sampson EL. Developing an applied model for making decisions towards the end of life about care for someone with dementia. PLoS One 2021; 16:e0252464. [PMID: 34043728 PMCID: PMC8158904 DOI: 10.1371/journal.pone.0252464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. AIM Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. METHODS Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018-2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. RESULTS Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. CONCLUSIONS The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers.
Collapse
Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Tanisha De Souza
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Greta Rait
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Jessica Meehan
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Elizabeth L. Sampson
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
| |
Collapse
|
12
|
Gallant NL, Peckham A, Marchildon G, Hadjistavropoulos T, Roblin B, Stopyn RJN. Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis. BMC Geriatr 2020; 20:458. [PMID: 33167897 PMCID: PMC7650170 DOI: 10.1186/s12877-020-01758-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/08/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts. METHODS Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations. RESULTS Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain. CONCLUSION The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.
Collapse
Affiliation(s)
- Natasha L. Gallant
- Department of Psychology and Center on Aging and Health, University of Regina, 3737 Wascana Parkway, Regina, Saskatchewan S4S 0A2 Canada
| | - Allie Peckham
- Edson College of Nursing and Health Innovation, Arizona State University, 550 N 3rd Street, Phoenix, AZ 85004 USA
- Institute of Health Policy, Management and Evaluation, University of Toronto, 425–155 College Street, Toronto, Ontario M5T 3M6 Canada
| | - Gregory Marchildon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 425–155 College Street, Toronto, Ontario M5T 3M6 Canada
| | - Thomas Hadjistavropoulos
- Department of Psychology and Center on Aging and Health, University of Regina, 3737 Wascana Parkway, Regina, Saskatchewan S4S 0A2 Canada
| | - Blair Roblin
- Institute of Health Policy, Management and Evaluation, University of Toronto, 425–155 College Street, Toronto, Ontario M5T 3M6 Canada
| | - Rhonda J. N. Stopyn
- Department of Psychology and Center on Aging and Health, University of Regina, 3737 Wascana Parkway, Regina, Saskatchewan S4S 0A2 Canada
| |
Collapse
|
13
|
Sutherland N. Structures, tensions, and processes shaping long-term care home staff's role in end of life decision-making for residents with dementia. J Aging Stud 2020; 54:100874. [PMID: 32972618 DOI: 10.1016/j.jaging.2020.100874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
Although long-term care (LTC) home staff of nurses and personal support workers spend the most time providing direct care, their role in end of life decision-making for residents with dementia has largely been unacknowledged. Staff's perceptions of their role play a significant part in how they support people with dementia and family care partners. The purpose of this study was to examine LTC home staff's perspectives of their role in end of life decision-making for LTC home residents with dementia. For this interpretive descriptive study, 21 semi-structured interviews were conducted in two urban LTC homes with nine personal support worker (PSWs), eight registered practical nurses (RPNs), and four registered nurses (RNs). Additionally, a focus group was conducted, consisting of each a PSW, RPN, and RN. A voice-centred relational analysis was used to situate LTC home staff's perspectives within broader social contexts. Findings suggest that little has changed in LTC homes in the last 50 years. Rooted in dichotomies between medical and social care paradigms, ideologies of rationality and professionalism created tensions, hierarchical roles, and staff's minimal involvement in decision-making. A relational approach is needed to account for the interdependency of care and the relationships that LTC home staff have with residents, family care partners, and the sociopolitical environment.
Collapse
Affiliation(s)
- Nisha Sutherland
- Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1, Canada.
| |
Collapse
|
14
|
Sawyer JM, Sallnow L, Kupeli N, Stone P, Sampson EL. Social networks, social capital and end-of-life care for people with dementia: a realist review. BMJ Open 2019; 9:e030703. [PMID: 31822539 PMCID: PMC6924787 DOI: 10.1136/bmjopen-2019-030703] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES (1) To develop an understanding of how social capital may be conceptualised within the context of end-of-life care and how it can influence outcomes for people with dementia and their families with specific reference to the context and mechanisms that explain observed outcomes. (2) To produce guidance for healthcare systems and researchers to better structure and design a public health approach to end-of-life care for people with dementia. DESIGN A realist review. DATA SOURCES MEDLINE, EMBASE, CINAHL and grey literature. ANALYSIS We conceptualised social capital as a complex intervention and, in order to understand how change is generated, used realist evaluation methods to create different configurations of context, mechanism and outcomes. We conducted an iterative search focusing on social capital, social networks and end-of-life care in dementia. All study designs and outcomes were screened and analysed to elicit explanations for a range of outcomes identified. Explanations were consolidated into an overarching programme theory that drew on substantive theory from the social sciences and a public health approach to palliative care. RESULTS We identified 118 articles from 16 countries ranging from 1992 to 2018. A total of 40 context-mechanism-outcome configurations help explain how social capital may influence end-of-life care for people with dementia. Such influence was identified within five key areas. These included: (1) socially orientating a person with dementia following diagnosis; (2) transitions in the physical environment of care; (3) how the caregiving experience is viewed by those directly involved with it; (4) transition of a person with dementia into the fourth age; (5) the decision making processes underpinning such processes. CONCLUSION This review contributes to the dispassionate understanding of how complex systems such as community and social capital might be viewed as a tool to improve end-of-life care for people with dementia. PROSPERO REGISTRATION NUMBER CRD42018084524.
Collapse
Affiliation(s)
- Joseph M Sawyer
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Libby Sallnow
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Camden, Islington ELiPSe and UCLH & HCA Palliative Care Service, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| |
Collapse
|
15
|
Bolt S, van der Steen J, Schols J, Zwakhalen S, Meijers J. What do relatives value most in end-of-life care for people with dementia? Int J Palliat Nurs 2019; 25:432-442. [DOI: 10.12968/ijpn.2019.25.9.432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background:End-of-life care for older people with dementia is often sub-optimal. Understanding the experiences of the relatives involved in the care of the person with dementia may help to improve care practice.Aims:To investigate relatives' experiences with end-of-life care for people with dementia, comparing the nursing home and home setting.Methods:In-depth interviews were conducted with 32 individuals who were bereaved of someone with dementia. Thematic analysis was performed to identify main themes from the data.Findings:Experiences translated into four themes: acknowledging human dignity; being recognised as an important caregiver; (not) talking about death and dying and making decisions together. A lack of person-centered care was mainly evident in nursing homes. Relatives took on a more prominent role in the care of the older person with dementia when the relative was cared for in a home setting and this involvement in the care of the older person was something that the relatives valued. Surrogate decision-making induced similar challenges in both settings.Conclusion:It is important that healthcare professionals inform and support relatives to help them make decision about end-of-life care and preferences. Nursing homes should learn to offer the same standard of person-centred care as a home care setting, and ensure that relatives are still involved in the care of the person with dementia.
Collapse
Affiliation(s)
- Sascha Bolt
- PhD candidate, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Jenny van der Steen
- Associate Professor, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands, Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Jos Schols
- Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Sandra Zwakhalen
- Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Judith Meijers
- Assistant Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands, Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| |
Collapse
|