Dying in long-term care facilities in Europe: the PACE epidemiological study of deceased residents in six countries

Impact of Spiritual Support Interventions on the Quality of Life of Patients Who Receive Palliative Care: A Systematic Review

BACKGROUND

Palliative care focuses on the prevention of worsening health, improving the quality of the patient's life, and the relief of suffering, and therefore has a considerable impact on both the patient suffering from a life-threatening or potentially life-threatening illness and on their family. Spirituality, as the dimension of human life involving the search for meaning, purpose, and transcendence, and connection with oneself, others, and the sacred, could be essential in supporting these patients. The aim of this study was to synthesise the scientific evidence describing the interventions and/or activities undertaken to meet the spiritual needs of the palliative patient.

METHODS

A literature search was carried out across the following databases: PubMed, LILACS, Scopus, and Web of Science. The PRISMA statement was used to guide this review.

RESULTS

Twenty-four articles were included. The thematic categories included spiritual needs at the end of life, the influence of music and dance as palliative care, care for family caregivers, and the comparison between counselling and dignity therapy.

CONCLUSIONS

Interventions in the biopsychosocial-spiritual spheres impact on the patient's peace of mind and promote the acceptance of a "good death". Healthcare personnel play an essential role in the way their patients prepare for the moment of death, and the meaning and values they convey help them to accompany and welcome patients. Last but not least, universities can play a crucial role by training nurses to integrate spiritual interventions such as music and dance, or by considering the family as a unit of care. The systematic review protocol was registered in the Prospective International Register of Systematic Reviews (PROSPERO) under protocol number CRD42023490852.

Challenges in recognizing and discussing changes in a resident's condition in the palliative phase: focus group discussions with nursing staff working in nursing homes about their experiences

BACKGROUND

Most nursing home residents have complex care needs, require palliative care and eventually die in these facilities. Timely recognition of changes in a resident's condition is crucial for providing appropriate care. Observations by nursing staff play a significant role in identifying and interpreting these changes.

METHODS

Focus group discussions were conducted with nursing staff from ten nursing homes in the Netherlands to explore their experiences and challenges in recognizing and discussing changes in a resident's condition. These discussions were analysed following the principles of thematic analysis.

RESULTS

The analysis of the challenges nursing staff face in identifying and interpreting changes in a resident's condition, resulted in three themes. First, that recognizing changes is considered complex, because it requires specialized knowledge and skills that is generally not part of their education and must partly be learned in practice. This also depends on how familiar the nursing staff is with the resident. Furthermore, different people observe residents through different lenses, depending on their relation and experiences with residents. This could lead to disagreements about the resident's condition. Lastly, organizational structures such as the resources available to document and discuss a resident's condition and the hierarchy between nursing home professionals often hindered discussions and sharing observations.

CONCLUSION

Nursing staff's experiences highlight the complexity of recognizing and discussing changes in nursing home residents' conditions. While supporting the observational skills of nursing staff is important, it is not enough to improve the quality of care for nursing home residents with palliative care needs. As nursing staff experiences challenges at different, interrelated levels, improving the process of recognizing and discussing changes in nursing home residents requires an integrated approach in which the organization strengthens the position of nursing staff. It is important that their observations become a valued and integrated and part of nursing home care.

Long term care facilities in England during the COVID-19 pandemic-a scoping review of guidelines, policy and recommendations

BACKGROUND

The disproportionate effect of COVID-19 on long term care facility (LTCF) residents has highlighted the need for clear, consistent guidance on the management of pandemics in such settings. As research exploring the experiences of LTCFs during the pandemic and the implications of mass hospital discharge, restricting staff movement, and limiting visitation from relatives are emerging, an in-depth review of policies, guidance and recommendations issued during this time could facilitate wider understanding in this area.

AIMS

To identify policies, guidance, and recommendations related to LTCF staff and residents, in England issued by the government during the COVID-19 pandemic, developing a timeline of key events and synthesizing the policy aims, recommendations, implementation and intended outcomes.

METHOD

A scoping review of publicly available policy documents, guidance, and recommendations related to COVID-19 in LTCFs in England, identified using systematic searches of UK government websites. The main aims, recommendations, implementation and intended outcomes reported in included documents were extracted. Data was analysed using thematic synthesis following a three-stage approach: coding the text, grouping codes into descriptive themes, and development of analytical themes.

RESULTS

Thirty-three key policy documents were included in the review. Six areas of recommendations were identified: infection prevention and control, hospital discharge, testing and vaccination, staffing, visitation and continuing routine care. Seven areas of implementation were identified: funding, collaborative working, monitoring and data collection, reducing workload, decision making and leadership, training and technology, and communication.

DISCUSSION

LTCFs remain complex settings, and it is imperative that lessons are learned from the experiences during COVID-19 to ensure that future pandemics are managed appropriately. This review has synthesized the policies issued during this time, however, the extent to which such guidance was communicated to LTCFs, and subsequently implemented, in addition to being effective, requires further research. In particular, understanding the secondary effects of such policies and how they can be introduced within the existing challenges inherent to adult social care, need addressing.

A Situation-Specific Theory of End-of-Life Communication in Nursing Homes

High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.

The Effect of Frailty Syndrome on the Quality of Life of Individuals with Parkinson's Disease: A Pilot Observational and Multicenter Study on the Polish Population

Parkinson's disease (PD) is a neurodegenerative disorder involving decreased dopamine release and atrophy of dopaminergic neurons of the substantia nigra. Frailty syndrome (FS) is common in older adults, which, in combination with PD symptoms, can substantially affect the quality of life (QOL). This study aimed to assess the prevalence of FS among PD patients and to identify variables affecting their QOL with particular attention to FS. The study included 296 patients (n = 173 women) with a mean age of 70.3 ± 5.7 years suffering from PD for an average of 8.2 ± 5.6 years. Patients were classified as at least stage II according to the Hoehn and Yahr scale. The following standardized questionnaires were used in the study: Schwab and England Activities of Daily Living (SE-ADL), Parkinson's Disease Questionnaire (PDQ-39), Beck Depression Inventory (BDI), Unified Parkinson's Disease Rating Scale (UPDRS), and Tilburg Frailty Indicator (TFI). FS was found in 96% (n = 283) of the PD patients studied. No depression occurred in 30% (n = 89) of subjects, moderate depression in 48% (n = 141) of subjects, and severe depression in 22% (n = 66) of subjects. The mean score of the PDQ-39 questionnaire in PD subjects with FS was 41.6 pts (min-max: 5.2-81.5 pts; SD = 17.4 pts), which was statistically significantly higher than in subjects without FS (p < 0.05). FS has been shown to be present in most of the subjects with PD. FS occurs more frequently with a longer PD period, which is associated with reduced physical capacity and QOL. Physical activity improves QOL and reduces disease progression. FS, similar to PD, is a common cause of disability in older adults and their dependency. Predictors such as depression, advanced stage of the disease, higher education, and low professional and economic status significantly affect the QOL level of PD patients. However, the results obtained among the Polish population of PD patients do not confirm the impact of FS on the QOL, so there is a need to conduct further research on this subject.

Design-Related Impacts on End-of-Life Experience: A Brief Report of Findings from an Exploratory Qualitative Study

BACKGROUND

Despite the general preference to die at home, many deaths occur in institutionalized settings. While biomedical interventions to ameliorate end-of-life (EoL) suffering have advanced, the end-of-life care (EoLC) environment is less understood as a means of palliative support.

OBJECTIVE

This exploratory study considered the implications of clinical EoLC environments (facility buildings and their adjacent areas), aiming to understand how these designed spaces may be improved to better support experiences for patients, families, and staff.

METHODS

Using an ethnography-driven approach, field observations (including participant commentaries) were captured at a standalone hospice and a palliative care ward at a general hospital. These were supplemented with semi-structured interviews. Content and thematic analyses were performed based on an interpretive-descriptive paradigm. Finally, informed by a review of field literature, analyses of all data were inter-related, and an interpretation was built to highlight key design considerations.

RESULTS

Through the analysis, 6 socio-spatial dimensions of EoLC facilities were identified (locational contexts; service administration & management; common spaces; private spaces; in-between spaces; and nature-integrated spaces) as guiding concepts to appraise and improve such settings.

CONCLUSION

Physical, emotional, and social wellbeing at the end of life is coalesced in and made visible by the designed environment. Therefore, evidence-based design serves as an important non-clinical intervention in such settings; however, patient involvement in such research remains difficult. Future scholarly research, new building schemes, and renovation projects should further examine the socio-spatial functions of clinical EoLC environments and investigate the challenges surrounding patient engagement within this domain.

Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study

BACKGROUND

Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care.

METHODS

In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs' judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner.

RESULTS

Younger RNs (P=.026), freelance RNs (P=.046), RNs with a permanent contract (P=.035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P<.012). Public ownership (odds ratio [OR]=9.88; 95% CI 2.22-44.03; P=.003), a higher proportion of residents with severe clinical conditions (OR=2.45; 95% CI 1.12-5.37; P=.025), a lower proportion of RNs (OR=2.24; 95% CI 1.10-4.54; P=.026), and perceived lack of time to care for residents (OR=2.33; 95% CI 1.04-5.26; P=.041) were statistically significantly associated with missed nursing care.

CONCLUSION

Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.

Professionals´ readiness for change to knowledge-based palliative care at nursing homes: a qualitative follow-up study after an educational intervention

Background

There has been a global increase in the number of people who are dying of old age. This development implies a need for good palliative care among older persons at the end of life. Here nursing homes have an important role to play. However, the principles of palliative care have not been sufficiently applied in nursing homes, and there is a need to increase the implementation of palliative care in these settings. Therefore the project named Implementation of Knowledge-Based Palliative Care in Nursing Homes (the KUPA project, to use its Swedish acronym) was started as a contribution to filling this knowledge gap. The aim of the present study was to investigate the professionals’ experiences of readiness for change to knowledge-based palliative care at nursing homes after the educational intervention within the KUPA project.

Methods

The focus group method was used to interview 39 health-care professionals with the aid of semistructured questions based on the Organizational Readiness for Change theoretical framework. Six focus groups were formed at six nursing homes in two counties in southern Sweden. The groups included different types of professionals: assistant nurses, nurses, occupational therapists, physiotherapists and social workers. The analysis was conducted with an abductive approach and included deductive and inductive content analysis.

Results

The analysis revealed one overarching theme: hopeful readiness for change in palliative care despite remaining barriers. The main categories were increased knowledge facilitating development, enhanced team spirit, uncertainty about future plans connected with hopeful readiness and remaining organizational barriers.

Conclusions

This study adds knowledge and understanding concerning professionals’ readiness for change palliative care in nursing homes and shows how ready nursing home settings undertake these changes in practice. The Organizational Readiness for Change theory proved suitable for application in nursing homes to assess the professionals’ experiences and to evaluate educational interventions regardless of the organization’s readiness for change.

Trial registration

ClinicalTrials NCT02708498, first registration 15/03/2016.

End-of-life care for older people: the way forward

Even though many older people will live longer in good health, many will also be confronted with frailty, multi-morbidity, cognitive decline, disability and serious illnesses in the last years of their life. The end-of-life trajectories of frail older people have a major impact on the care that needs to be provided. Older people develop different physical, psychological, and/or social needs in varying intensity during the last years of life. Moreover, determining a clear terminal phase of life is difficult in this population. In this commentary, we aim to highlight the importance of an integrated palliative, geriatric and rehabilitative care approach for older people, emphasizing the importance of setting-specific and cross-setting interventions. We stress the importance of person-centred care planning with the older patient and the role of their families, communities and society as a whole. We identify and formulate some of the research gaps that can be addressed in the near future.

Assessment of Physical Fitness and Risk Factors for the Occurrence of the Frailty Syndrome among Social Welfare Homes' Residents over 60 Years of Age in Poland

The study aimed at assessing physical fitness and occurrence of the frailty syndrome among social welfare homes’ residents as well as defining factors which determine the level of frailty and its occurrence. The examination included 198 residents (115 females and 83 males of average age 75.5 ± 10.21) and was carried out with the use of the Short Physical Performance Battery (SPPB) test with the following cut-off points: 0−6—frail, 7−9—pre-frail, 10−12—non-frail. The research additionally collected data regarding age, gender, number of chronic diseases, education level, type of prior work and current physical activity. In addition, the height and weight of the respondents were measured. The frailty syndrome was found in more than a half of the examinees (104; 52.53%), the pre-frailty state in 30.30% (n = 60) and 17.17% (n = 34) were non-frail. The average result of the SPPB test was 6.52 ± 2.73, which proves a moderate limitation of the sample group’s fitness. No significant differences were noted between female and male respondents (p = 0.27). The multifactorial linear regression model showed that independent and direct frailty syndrome predicators included age, number of chronic diseases and regular physical activity (p < 0.05). In conclusion, promoting and encouraging regular, age and interest-related forms of physical activity among seniors might foster the maintenance of their physiological reservoir and functional efficiency.

Trends in quality of care and dying perceived by family caregivers of nursing home residents with dementia 2005-2019

BACKGROUND

Dementia palliative care is increasingly subject of research and practice improvement initiatives.

AIM

To assess any changes over time in the evaluation of quality of care and quality of dying with dementia by family caregivers.

DESIGN

Combined analysis of eight studies with bereaved family caregivers' evaluations 2005-2019.

SETTING/PARTICIPANTS

Family caregivers of nursing home residents with dementia in the Netherlands (n = 1189) completed the End-of-Life in Dementia Satisfaction With Care (EOLD-SWC; quality of care) and Comfort Assessment in Dying (EOLD-CAD, four subscales; quality of dying) instruments. Changes in scores over time were analysed using mixed models with random effects for season and facility and adjustment for demographics, prospective design and urbanised region.

RESULTS

The mean total EOLD-SWC score was 33.40 (SD 5.08) and increased by 0.148 points per year (95% CI, 0.052-0.244; adjusted 0.170 points 95% CI, 0.055-0.258). The mean total EOLD-CAD score was 30.80 (SD 5.76) and, unadjusted, there was a trend of decreasing quality of dying over time of -0.175 points (95% CI, -0.291 to -0.058) per year increment. With adjustment, the trend was not significant (-0.070 EOLD-CAD total score points, 95% CI, -0.205 to 0.065) and only the EOLD-CAD subscale 'Well being' decreased.

CONCLUSION

We identified divergent trends over 14 years of increased quality of care, while quality of dying did not increase and well-being in dying decreased. Further research is needed on what well-being in dying means to family. Quality improvement requires continued efforts to treat symptoms in dying with dementia.

Attitudes toward withholding antibiotics from people with dementia lacking decisional capacity: findings from a survey of Canadian stakeholders

Background

Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity.

Methods

We conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death.

Results

Support for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics.

Conclusions

Findings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00689-1.

Large differences in the organization of palliative care in nursing homes in six European countries: findings from the PACE cross-sectional study

Background

To be able to provide high-quality palliative care, there need to be a number of organizational structures available in the nursing homes. It is unclear to what extent such structures are actually present in nursing homes in Europe. We aim to examine structural indicators for quality of palliative care in nursing homes in Europe and to evaluate the differences in terms of availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives.

Methods

A PACE cross-sectional study (2015) of nursing homes in Belgium, England, Finland, Italy, the Netherlands and Poland. Nursing homes (N = 322) were selected in each country via proportional stratified random sampling. Nursing home administrators (N = 305) filled in structured questionnaires on nursing home characteristics. Organization of palliative care was measured using 13 of the previously defined IMPACT structural indicators for quality of palliative care covering four domains: availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives. We calculated structural indicator scores for each country and computed differences in indicator scores between the six countries. Pearson’s Chi-square test was used to compute the p-value of each difference.

Results

The availability of specialist palliative care teams in nursing homes was limited (6.1–48.7%). In Finland, Poland and Italy, specialist advice was also less often available (35.6–46.9%). Up to 49% of the nursing homes did not provide a dedicated contact person who maintained regular contact with the resident and relatives. The 24/7 availability of opioids for all nursing home residents was low in Poland (37.5%).

Conclusions

This study found a large heterogeneity between countries in the organization of palliative care in nursing homes, although a common challenge is ensuring sufficient structural access to specialist palliative care services. Policymakers and health and palliative care organizations can use these structural indicators to identify areas for improvement in the organization of palliative care.

Hospitalisation in the last month of life and in-hospital death of nursing home residents: a cross-sectional analysis of six European countries

OBJECTIVES

To examine the rate and characteristics of hospitalisation in the last month of life and place of death among nursing home residents and to identify related care processes, facility factors and residents' characteristics.

SETTING

A cross-sectional study (2015) of deceased residents in 322 nursing homes in six European countries.

PARTICIPANTS

The nursing home manager (N=1634), physician (N=1132) and primary nurse (N=1384) completed questionnaires.

OUTCOME MEASURES

Hospitalisation and place of death were analysed using generalised linear and logistic mixed models. Multivariate analyses were conducted to determine associated factors.

RESULTS

Twelve to 26% of residents were hospitalised in the last month of life, up to 19% died in-hospital (p<0.001). Belgian residents were more likely to be hospitalised than those in Italy, the Netherlands and Poland. For those dying in-hospital, the main reason for admission was acute change in health status. Residents with a better functional status were more likely to be hospitalised or to die in-hospital. The likelihood of hospitalisation and in-hospital death increased if no conversation on preferred care with a relative was held. Not having an advance directive regarding hospitalisations increased the likelihood of hospitalisation.

CONCLUSIONS

Although participating countries vary in hospitalisation and in-hospital death rates, between 12% (Italy) and 26% (Belgium) of nursing home residents were hospitalised in the last month of life. Close monitoring of acute changes in health status and adequate equipment seem critical to avoiding unnecessary hospitalisations. Strategies to increase discussion of preferences need to be developed. Our findings can be used by policy-makers at governmental and nursing home level.

Effects of clown activities on patients eligible for palliative care in primary health care

OBJECTIVE

Evaluate the effects of clown activities on quality of life, depression, stress, anxiety, aid, and social support in patients eligible for palliative care (PC) attended in Primary Health Care (PHC).

METHOD

A quasi-experimental study, with pre-intervention and post-intervention evaluation, carried out with 16 patients eligible for early PC in PHC in a Midwestern city. Patients received 24 visits with home-based clown activities.

RESULTS

The interventions evidenced improved quality of life and social support, with significant results for the Social Activities dimension (p = 0.023). Increased scores for Anxiety (p = 0.007) and Depression (p = 0.023) were also observed.

CONCLUSION

Clown activities can bring positive results for the quality of life and social support of patients eligible for PC at home. They should be encouraged to interact with family knowledge and enhance humanized care, integral and centered on human relationships in PHC.

Advance care planning in nursing homes: new conversation and documentation tools

Although advance care planning (ACP) is highly relevant for nursing home residents, its uptake in nursing homes is low. To meet the need for context-specific ACP tools to support nursing home staff in conducting ACP conversations, we developed the ACP+intervention. At its core, we designed three ACP tools to aid care staff in discussing and documenting nursing home resident's wishes and preferences for future treatment and care: (1) an extensive ACP conversation guide, (2) a one-page conversation tool and (3) an ACP document to record outcomes of conversations. These nursing home-specific ACP tools aim to avoid a purely document-driven or 'tick-box' approach to the ACP process and to involve residents, including those living with dementia according to their capacity, their families and healthcare professionals.

Death and Dying in Long-Term Care Facilities: The Perception of Occupational Therapists

End-of-life care in long-term care facilities for older adults requires numerous skills. However, many professionals, including occupational therapists, feel unprepared to deal with death and dyingand have difficulties to attend to the real needs of the older adults and their families.This is a qualitative study anchored in phenomenologywhich had the objective to understand the perception of occupational therapists regarding death and dying inlong-term care facilities. Data were collected through focus groups and analyzed by thematic content analysis. A total of 12 occupational therapists participated in this study, and two themeswere generated: "The Experience of Death and Dying" and "The Occupational Therapist's approach in Facing Death and Dying". These results may contribute to improvingthe care provided to older adults in the process of death and dying.

Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries

CONTEXT

Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area.

OBJECTIVES

To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries.

METHODS

A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life.

RESULTS

We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%).

CONCLUSION

Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Supplementary Information

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

Dementia palliative care: A multi-site survey of long term care STAFF'S education needs and readiness to change

Many people with dementia reside in long-term care, where limited staff knowledge of dementia palliative care has been identified, along with poor awareness that a palliative approach can assist in identifying unmet care needs. Evidence-based guidance in palliative care for people with dementia is available however, implementing this guidance requires staff engagement and a tailored educational approach. This pre-implementation situational analysis informed a tailored staff education intervention to support the implementation of national guidance on dementia palliative care in long term care. Using a cross-sectional study design, underpinned by the Consolidated Framework for Implementation Research, survey data were collected on site profile, staff demographics, learning needs, and readiness-to change at three residential care sites for older people in Ireland. In total, 69 staff (predominantly nurses and healthcare attendants) completed the surveys. Medication management and management of pain were the most frequently identified learning needs. Staff were confident in their ability to implement change but de-motivation and powerlessness were substantial factors as only one-third of staff were "ready for change". Staffing levels, managing risk during change and perceived reluctance in others were common barriers. These results informed an educational intervention to address the specific care context, staff learning needs and barriers to change prior to implementation.

Higher Prevalence of Dementia but No Change in Total Comfort While Dying among Nursing Home Residents with Dementia between 2010 and 2015: Results from Two Retrospective Epidemiological Studies

Important policy developments in dementia and palliative care in nursing homes between 2010 and 2015 in Flanders, Belgium might have influenced which people die in nursing homes and how they die. We aimed to examine differences between 2010 and 2015 in the prevalence and characteristics of residents with dementia in nursing homes in Flanders, and their palliative care service use and comfort in the last week of life. We used two retrospective epidemiological studies, including 198 residents in 2010 and 183 in 2015, who died with dementia in representative samples of nursing homes in Flanders. We found a 15%-point increase in dementia prevalence (p-value < 0.01), with a total of 11%-point decrease in severe to very severe cognitive impairment (p = 0.04). Controlling for residents’ characteristics, in the last week of life, there was an increase in the use of pain assessment (+20%-point; p < 0.03) but no change in total comfort. The higher prevalence of dementia in nursing homes with no change in residents’ total comfort while dying emphasizes an urgent need to better support nursing homes in improving their capacities to provide timely and high-quality palliative care services to more residents dying with dementia.

"We are to be like machines…fill the bed before it gets cold": Exploring the emotional geographies of healthcare providers caring for dying residents in long-term care facilities

The end-of-life context is imbued with emotions, with death and dying transforming everyday places, like long-term care facilities, into entirely new emotional topographies that can evoke profound effects on those who live and work within these settings. Despite their significant role, healthcare providers' emotions and their interconnections with 'place' have received relatively little attention from researchers, including geographers of care and caregiving. This secondary thematic analysis attempts to address this notable gap by exploring the emotional geographies of healthcare providers caring for dying residents in four long-term care facilities in western Canada. By drawing upon interview and focus group data with administrators (n = 12) and direct care provider (n = 80) participants, findings reveal that experiences of caring for dying residents were often charged with negative emotions (e.g., distress, frustration, grief). These emotions were not only influenced by social and physical aspects of 'place', but the temporal process of caring for a dying resident, which included: (1) Identifying a resident as in need of a palliative approach to care; (2) Actively dying; and (3) Following a resident's death. Findings indicate that providers' emotions shifted in scale at each of these temporal phases, ranging from association with the facility as a whole to the micro-scale of the body. Broader structural forces that influence the physical and social place of long-term care facilities were also found to shape experiences of emotional labor among staff. With an increasing number of deaths occurring within long-term care facilities throughout the Global North, such findings contribute critical experiential knowledge that can inform policy and programs on ways to help combat staff burnout, facilitate worker satisfaction, and foster resilience among long-term care providers, ensuring they receive the necessary supports to continue fulfilling this valuable caring role.

Pilot Study to Develop and Test Palliative Care Quality Indicators for Nursing Homes

An increasingly frail population in nursing homes accentuates the need for high quality care at the end of life and better access to palliative care in this context. Implementation of palliative care and its outcomes can be monitored by using quality indicators. Therefore, we developed a quality indicator set for palliative care in nursing homes and a tailored measurement procedure while using a mixed-methods design. We developed the instrument in three phases: (1) literature search, (2) interviews with experts, and (3) indicator and measurement selection by expert consensus (RAND/UCLA). Second, we pilot tested and evaluated the instrument in nine nursing homes in Flanders, Belgium. After identifying 26 indicators in the literature and expert interviews, 19 of them were selected through expert consensus. Setting-specific themes were advance care planning, autonomy, and communication with family. The quantitative and qualitative analyses showed that the indicators were measurable, had good preliminary face validity and discriminative power, and were considered to be useful in terms of quality monitoring according to the caregivers. The quality indicators can be used in a large implementation study and process evaluation in order to achieve continuous monitoring of the access to palliative care for all of the residents in nursing homes.

Time from dementia diagnosis to nursing-home admission and death among persons with dementia: A multistate survival analysis

Objectives

To estimate transition times from dementia diagnosis to nursing-home (NH) admission or death and to examine whether sex, education, marital status, level of cognitive impairment and dementia aetiology are associated with transition times.

Design

Markov multistate survival analysis and flexible parametric models.

Setting

Participants were recruited from the Norwegian Registry of Persons Assessed for Cognitive Symptoms (NorCog) in specialist healthcare between 2008 and 2017 and followed until August 2019, a maximum of 10.6 years follow-up time (mean 4.4 years, SD 2.2). Participants’ address histories, emigration and vital status were retrieved from the National Population Registry from time of diagnosis and linked to NorCog clinical data.

Participants

2,938 home-dwelling persons with dementia, ages 40–97 years at time of diagnosis (mean 76.1, SD 8.5).

Results

During follow-up, 992 persons (34%) were admitted to nursing-homes (NHs) and 1,556 (53%) died. Approximately four years after diagnosis, the probability of living in a NH peaked at 19%; thereafter, the probability decreased due to mortality. Median elapsed time from dementia diagnosis to NH admission among those admitted to NHs was 2.28 years (IQR 2.32). The probability of NH admission was greater for women than men due to women´s lower mortality rate. Persons living alone, particularly men, had a higher probability of NH admission than cohabitants. Age, dementia aetiology and severity of cognitive impairment at time of diagnosis did not influence the probability of NH admission. Those with fewer than 10 years of education had a lower probability of NH admission than those with 10 years or more, and this was independent of the excess mortality in the less-educated group.

Conclusion

Four years after diagnosis, half of the participants still lived at home, while NH residency peaked at 19%. Those with fewer than 10 years of education were less often admitted to NH.

Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians' and nurse practitioners' perceptions

Background

The Liverpool care pathway for the dying patient (LCP) is a multidisciplinary tool developed for the dying phase for use in palliative care settings. The literature reports divergent experiences with its application in a nursing home setting related to its implementation and staff competencies. The aim of this study is to understand how the LCP is being used in the context of the nursing home, including for residents with dementia, and experienced from the perspectives of those responsible for medical treatment in nursing homes.

Methods

A mixed-methods approach was used, consisting of a survey followed by interviews. A link to a 9-item online survey with closed and open-ended questions was emailed to all physicians and nurse practitioners of 33 care organisations with nursing homes in three regions of the Netherlands (North, West and South). In addition, 10 respondents with particularly positive or negative experiences were selected for semi-structured interviews.

Results

The survey was completed by 159 physicians and nurse practitioners. The respondents were very positive on the content and less positive on the use of the LCP, although they reported difficulties identifying the right time to start the LCP, especially in case of dementia. Also using the LCP was more complicated after the implementation of the electronic health record. The LCP was judged to be a marker of quality for the assessment of symptoms in the dying phase and communication with relatives.

Conclusion

An instrument that prompts regular assessment of a dying person was perceived by those responsible for (medical) care to contribute to good care. As such, the LCP was valued, but there was a clear need to start it earlier than in the last days or hours of life, a need for a shorter version, and for integration of the LCP in the electronic health record. Regular assessments with an instrument that focusses on quality of care and good symptom control can improve palliative care for nursing home residents with and without dementia.

Gaps in end-of-life care and lack of support for family carers in Poland and Central Eastern Europe

The growth of life expectancy in Central Eastern Europe and increase in the number of older people in that region are the consequences of changes in the 1990s period, connected to transition from the communism into a market economy. Central Eastern Europe is already facing consequences of fast ageing and insufficient development of state health care and social services. Those result in gaps in the provision of end-of-life care and overburden of family caregivers. This essay addresses gaps in end-of-life care, showing the development of hospice-palliative care on one side, and highlighting main problems with long-term care on the other. There is scarce support for informal caregivers and lack of cooperation between health and social care. End-of-life care is over medicalized in hospice-palliative care and hardly existing in long-term care. Dying is more a social than medical event, and as such, it should be cared for by compassionate communities, encouraging cooperation of professionals with family caregivers and society. Unfortunately, to date, there is no adequate cooperation in social dimension of end-of-life care in most of Central Eastern Europe. The social dimension of end-of-life care has to be recognized and empowered with the health promoting palliative care and introduction of compassionate communities in Central Eastern Europe.

International COVID-19 Palliative Care Guidance for Nursing Homes Leaves Key Themes Unaddressed

COVID-19 mortality disproportionally affects nursing homes, creating enormous pressures to deliver high-quality end-of-life care. Comprehensive palliative care should be an explicit part of both national and global COVID-19 response plans. Therefore, we aimed to identify, review, and compare national and international COVID-19 guidance for nursing homes concerning palliative care, issued by government bodies and professional associations. We performed a directed documentary and content analysis of newly developed or adapted COVID-19 guidance documents from across the world. Documents were collected via expert consultation and independently screened against prespecified eligibility criteria. We applied thematic analysis and narrative synthesis techniques. We identified 21 eligible documents covering both nursing homes and palliative care, from the World Health Organization (n = 3), and eight individual countries: U.S. (n = 7), The Netherlands (n = 2), Ireland (n = 1), U.K. (n = 3), Switzerland (n = 3), New Zealand (n = 1), and Belgium (n = 1). International documents focused primarily on infection prevention and control, including only a few sentences on palliative care-related topics. Palliative care themes most frequently mentioned across documents were end-of-life visits, advance care planning documentation, and clinical decision making toward the end of life (focusing on hospital transfers). There is a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. Most have a limited focus both regarding breadth of topics and recommendations made. Key aspects of palliative care, that is, symptom management, staff education and support, referral to specialist services or hospice, and family support, need greater attention in future guidelines.