Family perspectives on and experiences with advance care planning in nursing homes: A thematic synthesis

OBJECTIVES

To synthesize family members' experiences and perspectives on advance care planning (ACP) in nursing homes.

METHODS

The thematic synthesis is reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A systematic search of the APA PsycINFO, CINAHL Plus, Embase and PubMed databases is initially conducted in October 2022, and the search is updated in January 2024. Qualitative studies that presented family members' quotes regarding advance care planning in nursing homes published in a peer-reviewed journal were included. Screening and data extraction were independently performed by two reviewers, and any discrepancies were resolved with the assistance of the third author.

RESULTS

A total of 1027 articles were identified, and 23 articles were included in the full-text review. Subsequently, a total of 17 studies were ultimately included, and 127 quotes were extracted and analysed. The main findings were categorized into three themes: (1) invitation to conversation and care, (2) the resident's surrogate and (3) nurses. Considering the importance of family members' roles in ACP conversations in a nursing home setting, this study provided an in-depth understanding of family members' perceptions and experiences of ACP by synthesizing qualitative studies. Family members' lack of knowledge regarding the timing and pursuits of ACP was also identified.

CONCLUSION

The findings of this study provide synthesized qualitative evidence of family members' perspectives on ACP, which can inform care and treatment in nursing homes. As this study synthesizes the experiences of family members in nursing homes about ACP, the findings of this study contribute to reflecting family members' experiences and providing evidence for nursing home healthcare professionals.

PATIENT OR PUBLIC CONTRIBUTION

This study reports the experiences of family members in ACP nursing homes. The findings of this study contribute to reflecting family members' experiences and building evidence for nursing home healthcare professionals.

Perceptions of Older People in Nursing Facilities About Advance Care Planning: A Systematic Review

BACKGROUND

With the ageing of the population intensifying, the implementation of advance care planning (ACP) in nursing facilities is especially crucial.

OBJECTIVE

This study aimed to search and synthesise qualitative studies exploring the perspectives of older people in nursing facilities about ACP discussions.

METHODS

The researchers conducted searches of PubMed, Web of Science, Cochrane Library, CNKI, Wanfang, VIP and CBM between the time of inception and October 2023. The PICo model was used to build the inclusion and exclusion criteria. Following the inclusion and exclusion criteria, two researchers screened the literature, extracted data and then integrated the literature using the integrative synthesis.

RESULTS

A total of 12 articles were included, 47 themes were extracted, and three research integrations were summarised: (1) understanding of ACP; (2) attitude towards ACP; and (3) influencing factors of participation in ACP.

CONCLUSION

This study offers guidance for the future development of ACP on the participation of older people in nursing facilities.

IMPLICATIONS FOR PRACTICE

It is necessary to strengthen the education of ACP-related knowledge in conjunction with the cultural characteristics of different countries, to provide interdisciplinary support for older people through professional teamwork and to promote the development and improvement of ACP-related practices.

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study

Background

Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this.

Objective

To co-design and implement a scalable UK model of Needs Rounds.

Design

A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework.

Setting

Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each.

Participants

Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings).

Interventions

(1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings.

Main outcome measures

A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement.

Data sources

Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members.

Results

The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality.

Limitations

COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care.

Conclusions

Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff.

Future work

Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care.

Study registration

This study is registered as ISRCTN15863801.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.

Using participatory research to co-produce an education and training e-resource to support care home staff to meet the sexuality, intimacy and relationship needs of care home residents with and without dementia

Aim

To present the methodological approach and research methods chosen in a research study designed to enable the collaborative creation of an education and training e-resource designed to facilitate and support care home staff to address the sexuality, intimacy and relationship needs of older care home residents.

Design

Co-production using community-based participatory approach.

Methods

Four participatory workshops with care home staff, residents and their significant others.

Results

Workshops 1 and 2 identified and developed real-world case scenarios related to sexuality, intimacy and relationship needs and identified care staff training needs in this area. Then workshop 3 provided valuable feedback on the prototype training e-resource, and the final workshop identified care home staff engagement with and implementation of the e-resource in practice.

Conclusion

The findings provide evidence that using participatory approaches, such as co-production, to develop education and training resources in a sensitive subject area with care home residents, significant others, carers and care home staff, was a useful approach in engaging a vulnerable population group, in a sensitive area. However, this approach is not without challenges in care home communities.

Implementing and evaluating online advance care planning training in UK nursing homes during COVID-19: findings from the Necessary Discussions multi-site case study project

BACKGROUND

Advance care planning in nursing homes is important to ensure the wishes and preferences of residents are recorded, especially during the COVID-19 pandemic. However, care staff and family members frequently report feeling unprepared for these conversations. More resources are needed to support them with these necessary discussions. This research aimed to develop, implement and evaluate a website intervention for care staff and family members to provide training and information about advance care planning during COVID-19.

METHODS

The research was a primarily qualitative case study design, comprising multiple UK nursing home cases. Data collection included semi-structured interviews with care staff and family members which were coded and analysed thematically. A narrative synthesis was produced for each case, culminating in a thematic cross-case analysis of the total findings. Theoretical propositions were refined throughout the research.

RESULTS

Eight nursing homes took part in the study, involving 35 care staff and 19 family members. Findings were reported according to the RE-AIM framework which identified the reach, effectiveness, adoption, implementation and maintenance of the intervention. Themes included: website content that was well received; suggestions for improvement; implementation barriers and facilitators; examples of organisational and personal impact.

CONCLUSIONS

Four theoretical propositions relating to advance care planning in nursing homes are presented, relating to: training and information needs, accessibility, context, and encouraging conversations. Implications for practice and training include an awareness of diverse learning styles, re-enforcing the right to be involved in advance care planning and encouraging opportunities for facilitated discussion.

TRIAL REGISTRATION

ISRCTN registry (ID 18003630 ) on 19.05.21.

Factors associated with willingness to complete advance directives in older adults

This study aimed to examine the factors associated with willingness to complete advance directives (ADs) in community-dwelling older adults. In total, 121 community-dwelling older adults in Korea completed the questionnaires inquiring about their willingness and perceptions in completing ADs (susceptibility, severity, benefits, barriers, and cues to action), which were based on the Health Belief Model. The mean score for willingness to complete ADs was 6.2 (SD = 3.6). A multiple linear regression analysis showed that higher scores of perceived severity (β = 0.199, p = 0.021), perceived benefits (β = 0.221, p = 0.016), and cues to action (β = 0.159, p = 0.030) were associated with a greater willingness to complete ADs. However, higher scores of perceived barriers (β = -0.409, p < 0.001) were likely to lower the willingness to complete ADs. This study highlights that future interventions aimed at increasing AD completion rates in older adults should consider improving perceived severity, benefits, and cues to action and minimizing perceived barriers.

Informal caregivers and advance care planning: systematic review with qualitative meta-synthesis

BACKGROUND

Advance care planning (ACP) is a communication process about a person's values, life goals and preferences for current and future treatment and care. It can improve end-of-life care experiences for care recipients as well as for family caregivers. Knowledge about caregivers' needs might support implementation of ACP interventions suitable to both care recipients and their caregivers.

OBJECTIVE

To explore the experiences and attitudes of informal family caregivers, and their knowledge, regarding ACP.

METHODS

A systematic literature search was conducted (participants: family caregivers; intervention: advance care planning; databases: MEDLINE, PsycINFO, CINAHL, Cochrane Library). Thematic synthesis was applied to qualitative and mixed methods studies; quantitative studies were described in relation to the themes of the meta-synthesis.

RESULTS

57 studies were included, of these 51 in the meta-synthesis. Three themes emerged: (1) caregiver's individual conceptualisation of ACP, (2) caregiver's relationships and (3) ACP process. These themes were incorporated into a longitudinal perspective on the caregiver's ACP trajectory, encompassing the phases (A) life before, (B) ACP process, (C) utilisation of ACP and (D) life after. The implications for ACP activities are described according to each phase.

CONCLUSION

For the benefit of care recipients, healthcare professionals should carefully consider caregivers' conceptualisations of ACP as well as the relationships within the family. They need to be skilled communicators, sensitive to individual needs and equipped with sufficient time resources to tailor ACP interventions to their clients' unique situation. Thus, they will support decision-making according to care recipients' wishes, caregivers' end-of-life experience and their life after bereavement.

PROSPERO REGISTRATION NUMBER

CRD42018082492.

"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.

Elephant in the room - Family members´ perspectives on advance care planning

OBJECTIVE

To explore family members' experiences of advance care planning in nursing homes.

DESIGN

Individual interviews. Thematic analysis.

SETTING

Four nursing homes in Sweden.

SUBJECTS

Eighteen family members of deceased nursing home patients.

MAIN OUTCOME MEASURES

Family members' experiences of advance care planning in nursing homes.

RESULTS

Family members' experiences of advance care planning in a nursing home context involved five themes: Elephant in the room, comprising end-of-life issues being difficult to talk about; Also silent understanding, e.g. patient's preferences explicitly communicated, but also implicitly conveyed. In some cases family members had a sense of the patient's wishes although preferences had not been communicated openly; Significance of small details, e.g. family members perceive everyday details as symbols of staff commitment; Invisible physician, supporting nurse, e.g. nurse being a gatekeeper, providing a first line assessment in the physician's absence; and Feeling of guilt, e.g. family members wish to participate in decisions regarding direction of care and treatment limits, and need guidance in the decisions.

CONCLUSION

Our study stresses the significance of staff involving the patient and family members in the advance care planning process in nursing homes, thereby adapting the care in line with patient's wishes, and for the patient to share these preferences with family members. Education in communication related to the subject may be important to shape advance care planning. Key points Knowledge on advance care planning (ACP) in a nursing home (NH) context from the perspective of family members is limited. Role of the nurse in ACP is seen as central, whereas physician involvement is often perceived to be lacking. Significance of small details, perceive to symbolize staff competence and respect for patient autonomy. To limit family members' feeling of guilt, communicating end-of-life issues is important in order to align ACP with patient preferences.

Nursing facility residents' cardiopulmonary resuscitation decisions

CONTEXT

As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting.

OBJECTIVES

The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions.

METHODS

We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents' views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting.

RESULTS

Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) 'Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR.

CONCLUSIONS

Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP.

IMPLICATIONS FOR PRACTICE

ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.

Understanding the Outcomes of Supplementary Support Services in Palliative Care for Older People. A Scoping Review and Mapping Exercise

CONTEXT

Supplementary support services in palliative care for older people are increasingly common, but with neither recommended tools to measure outcomes nor reviews synthesizing anticipated outcomes. Common clinically focused tools may be less appropriate.

OBJECTIVES

To identify stakeholder perceptions of key outcomes from supplementary palliative care support services, then map these onto outcome measurement tools to assess relevance and item redundancy.

METHODS

A scoping review using the design by Arksey and O'Malley. EMBASE, CINAHL, MEDLINE, and PSYCHinfo searched using terms relating to palliative care, qualitative research, and supplementary support interventions. Articles were imported into Endnote™, and Covidence™ was used by two reviewers to assess against inclusion criteria. Included articles were imported into NVivo™ and thematically coded to identify key concepts underpinning outcomes. Each item within contender outcome measurement tools was assessed against each concept.

RESULTS

Sixty included articles focused on advance care planning, guided conversations, and volunteer befriending services. Four concepts were identified: enriching relationships; greater autonomy and perceived control; knowing more; and improved mental health. Mapping concepts to contender tool items revealed issues of relevance and redundancy. Some tools had no redundant items but mapped only to two of four outcome themes; others mapped to all concepts, but with many redundant questions. Tools such as ICECAP-Supportive Care Measure and McGill Quality of Life had high relevance and low redundancy.

CONCLUSION

Pertinent outcome concepts for these services and population are not well represented in commonly used outcome measurement tools, and this may have implications in appropriately measuring outcomes. This review and mapping method may have utility in fields where selecting appropriate outcome tools can be challenging.

Care home residents who die in hospital: exploring factors, processes and experiences

BACKGROUND

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.

METHODS

This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.

RESULTS

During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.

CONCLUSIONS

Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.

Wishes and needs of nursing home residents and their relatives regarding end-of-life decision-making and care planning-A qualitative study

AIMS AND OBJECTIVES

To explore wishes and needs, such as existing and preferred communication processes, of residents and relatives regarding medical and nursing planning at the end of life.

BACKGROUND

Nursing home residents are a relevant target group for advance care planning (ACP) due to their high age and multimorbidity. Their relatives seem to be important partners in terms of communication and their documentation of wishes and needs.

DESIGN

A qualitative descriptive design was used.

METHODS

Thirty-two guideline-based interviews with nursing home residents (n = 24) and relatives (n = 8) were conducted in nursing homes in Germany (n = 7). All interviews were analysed by content-structured content analysis. The COREQ checklist was used to document reporting of the study.

RESULTS

Residents particularly express wishes and needs regarding their health, like the desire to maintain or improve one's current state of health and to be active and mobile and also regarding their social situation, for example the well-being of relatives and beloved ones. A limited group of people was identified with whom residents spoke about issues such as preparedness and self-determination. These were mainly their relatives. Relatives themselves have a need for more communication. Various communication barriers could be identified.

CONCLUSION

Residents express diverse and partly explicit wishes and needs. Although many of the respondents had already drafted advanced directives, the demand for offers of communication to plan ahead for the end of life remains clear. The results indicate the unconditional participation of relatives and people close to the residents, if they are available.

RELEVANCE TO CLINICAL PRACTICE

Derivations for a target group-related ACP concept in the study region are identified. Besides the involvement of relatives, nurses could also be involved in the communication and decision-making process of residents in nursing homes under certain conditions.

Delivering an advance care planning facilitated model

BACKGROUND

Advance care planning is increasingly recognised as an integral part of achieving excellence at the end of life (EoL), but barriers still prevent individuals from having the opportunity to discuss their wishes and preferences for the future.

AIM

To describe the development and initial evaluations of an innovative facilitated ACP model, the ACP Triple E, which empowers individuals through education to engage in ACP conversations.

METHODS

This model uses a collaborative approach involving all sectors of a large university health board to equip all health and social care professionals with the knowledge, skills and confidence to engage in ACP discussion and also raise public awareness of the benefits of ACP.

CONCLUSION

This model includes recognised elements that support successful implementation of ACP. Initial evaluations of the model are extremely positive. Further analysis of the data is now needed to evaluate the model's flexibility and its ability to change practice and achieve strategic objectives.

Nursing home staff members' knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes

BACKGROUND

Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries.

AIMS

To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy.

METHODS

Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants' characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents.

RESULTS

Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals' knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators.

DISCUSSION

Nursing home staff members' concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it.

CONCLUSIONS

A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.

A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care

OBJECTIVES

Long-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness.

DESIGN

A multicenter, cross-sectional survey study.

SETTING AND PARTICIPANTS

1184 LTC clinicians from 34 Ontario LTC homes were invited to participate.

MEASURES

The questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers.

RESULTS

The overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings.

CONCLUSIONS AND IMPLICATIONS

This study has identified key LTC clinician-identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions.

Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness

This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.

Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model

BACKGROUND

Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations.

AIM

To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development.

DESIGN

A structured integrative review of relevant literature.

DATA SOURCES

CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018.

RESULTS

From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality.

CONCLUSION

Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.

Advance care planning: what do patients want?

Introduction:

Advance care planning is the process by which patients can make decisions about their future health care should they lose capacity. Such conversations are shown to improve quality of life and reduce institutionalization. This article explores the preferences and wishes of patients in terms of advance care planning.

Methods:

CINAHL, Medline, Embase and Pubmed were searched. Key words included ‘elderly’, ‘advance care planning’, ‘advance directive’, ‘views’ and ‘opinions’.

Results:

A total of 64 abstracts were screened and 20 full text articles read; 11 articles were included in the final study. Individual and cultural differences influence the level of decision making that patients want. Most studies agreed that conversations should be carried out opportunistically by a trained health-care professional. Patients value honest and open conversations, without which they may make misinformed decisions.

Conclusions:

The level of shared decision making that individuals personally want should be established. Open and honest conversations should be initiated at the earliest opportunity.

Facilitators and barriers to advance care planning implementation in Australian aged care settings: A systematic review and thematic analysis

OBJECTIVES

There are many studies investigating implementation of advance care planning (ACP) in aged care around the world, but few studies have investigated Australian settings. The objective of this study was to determine facilitators and barriers to implementation of ACP in Australian residential and community aged care.

METHODS

Evidence from Australian studies published between 2007 and September 2017 of ACP in residential and community aged care was sourced from electronic databases using predetermined search strategies. Data were extracted and synthesised using thematic analysis, and summarised according to themes.

RESULTS

Nine studies described facilitators and barriers of ACP implementation. Six themes were identified: "Education and Knowledge," "Skills and Training," "Procedures and Resources," "Perceptions and Culture," "Legislation" and "Systems."

CONCLUSIONS

A whole of systems approach is necessary to facilitate uptake of ACP in residential aged care settings. More research is needed to understand facilitators and barriers to ACP in community aged care.

Conversations about Death and Dying with Older People: An Ethnographic Study in Nursing Homes

Nursing homes are often places where older persons “come to die.” Despite this, death and dying are seldom articulated or talked about. The aim of this study was to explore assistant nurses’ experiences of conversations about death and dying with nursing home residents. This study is part of an implementation project through a knowledge-based educational intervention based on palliative care principles. An ethnographic study design was applied in seven nursing homes, where eight assistant nurses were interviewed and followed in their daily assignments through participant observations. The assistant nurses stated that they had the knowledge and tools to conduct such conversations, even though they lacked the time and felt that emotional strain could be a hinder for conversations about death and dying. The assistant nurses used the strategies of distracting, comforting, and disregarding either when they perceived that residents’ reflections on death and dying were part of their illness and disease or when there was a lack of alignment between the residents’ contemplations and the concept of dying well. They indicated that ambivalence and ambiguity toward conversations about death and dying should be taken into consideration in future implementations of knowledge-based palliative care that take place in nursing homes after this project is finalized.

End-of-life care in UK care homes: a systematic review of the literature

BACKGROUND

The number of people requiring end-of-life care provision in care homes has grown significantly. There is a need for a systematic examination of individual studies to provide more comprehensive information about contemporary care provision.

AIM

The aim of this study was to systematically review studies that describe end-of-life care in UK care homes.

METHOD

A systematic PRISMA review of the literature published between 2008 and April 2017 was carried out. A total of 14 studies were included in the review.

RESULTS

A number of areas of concern were identified in the literature in relation to the phases of dying during end-of-life care: end-of-life pre-planning processes; understandings of end-of-life care; and interprofessional end-of-life care provision.

CONCLUSIONS

Given that the problems identified in the literature concerning end-of-life care of residents in care homes are similar to those encountered in other healthcare environments, there is logic in considering how generalised solutions that have been proposed could be applied to the specifics of care homes. Further research is necessary to explore how barriers to good end-of-life care can be mitigated, and facilitators strengthened.

Discussing advance care planning: insights from older people living in nursing homes and from family members

ABSTRACTBackground:Evidence concerning when and in which manner older people living in nursing homes (NHs) would prefer to discuss advance care planning (ACP) is still scarce. This study explored the attitudes of NH residents and family members toward ACP and their opinions as to the right time to broach the subject, the manner in which it should be approached, and the content of ACP.

METHODS

This was a qualitative study using face-to-face interviews with 30 residents (age range 66-94), and 10 family members from 4 Italian NHs. The interviews were analyzed using content analysis.

RESULTS

Three main themes were identified: (1) life in the NH, including thoughts about life in a nursing home, residents' concerns, wishes and fears, and communication barriers; (2) future plans and attitudes toward ACP, including attitudes toward planning for the future and plans already made, and attitudes toward and barriers against ACP; (3) contents and manner of ACP, including contents of ACP discussions, the right moment to introduce ACP, with whom it is better to discuss ACP, and attitudes toward advance directives.

CONCLUSIONS

ACP was a welcome intervention for the majority of participants, but an individualized assessment of the person's readiness to be involved in ACP is needed. For people with dementia, it is essential to identify the right time to introduce ACP before NH admission. Participants in our study suggested that ACP should include palliative care and practical issues, and that in the NH setting all staff and family members may have a valuable role in ACP.

Family perceptions of care at the end of life in UK nursing care homes

Background

Over a fifth of the population of developed countries die in care homes. While studies are emerging on the outcomes of care in the last few weeks of life, few report on the experience as perceived by the family members.

Methods

As part of a wider study to improve the delivery of end-of-life care, bereaved relatives of residents who had died in a care home/hospital were sent the Family Perception of Care Scale questionnaire to evaluate their experience of care provision for their relative in the last month of life. The Family Perception of Care Scale questionnaire was posted to bereaved relatives, from 37 nursing care homes in south-east England, 3-6 months following the resident's death. The questionnaires were posted over a 14-month period from 1 October 2009 to 31 November 2010.

Results

A total of 869 questionnaires were posted, with a 42% response rate. A global question within the Family Perception of Care Scale looking at the overall satisfaction with the quality of end-of-life care (Q24) indicated that bereaved relatives were satisfied with the care provided. Qualitative responses from family members highlighted some excellent care, although issues in relation to medical input, professional teamwork, last days of life and spiritual care remain problematic. Results provide an important insight into care provision at the end of life within these care homes.

Conclusion

While some issues can be addressed through education, relationships and value-based issues are likely to be more difficult to address in light of increasing pressure of healthcare support for UK care homes.

Perspectives of older people living in long-term care facilities and of their family members toward advance care planning discussions: a systematic review and thematic synthesis

Objective

We aimed to search and synthesize qualitative studies exploring the perspectives of older people living in long-term care facilities and of their family members about advance care planning (ACP) discussions.

Methods

The enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) framework was used to guide the review and report its results. PubMed, CINAHL, and PsycINFO were searched for studies published between January 2000 and November 2015. All included studies were assessed for comprehensiveness of reporting, and a thematic synthesis of their results was performed.

Results

The nine included studies differed in terms of qualitative method used, comprehensiveness of reporting, and geographical origin. The thematic synthesis led to the identification of four main themes: 1) plans already made; 2) end-of-life care and decision-making; 3) opinions and attitudes toward ACP; and 4) how, when, about what, and with whom to do ACP.

Conclusion

Despite their willingness to be involved in a shared decision-making process, older residents and their families still have little experience with ACP.

Practical implications

In view of implementing ACP for elders living in long-term care facilities, it would be important to rethink ACP and also to incorporate their nonmedical preferences, according to their own priorities.

Preconditions for successful advance care planning in nursing homes: A systematic review

OBJECTIVES

There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs.

DESIGN

A systematic review.

DATA SOURCES

PubMed, PsycINFO, EMBASE and CINAHL.

REVIEW METHODS

Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify "preconditions", defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life.

MAIN FINDINGS

Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home.

CONCLUSION

There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself.

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review

BACKGROUND

Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference.

AIM

To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions.

DESIGN

Systematic review of the English language articles published from January 2000 to April 2015.

DATA SOURCES

EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists.

RESULTS

A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available.

CONCLUSION

Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.

They know!-Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes

BACKGROUND

Residents living in long-term care facilities are a vulnerable population. For many residents, a nursing home is their place of death. Palliative care and end-of-life decisions are important components of their care provision.

AIM

To study the views of cognitively able residents and relatives on advance care planning, end-of-life care, and decision-making in nursing homes.

DESIGN

A qualitative study with in-depth interviews with nursing home residents and focus group interviews with relatives of nursing home residents. Analysis is based on interpretive description.

SETTING/PARTICIPANTS

In total, 43 informants from nine nursing homes participated in the study (25 nursing home residents and 18 relatives). All included residents had capacity to provide informed consent and lived in long-term care.

RESULTS

The main findings of this study were the differing views about decision-making and advance care planning of residents and relatives. Residents do trust relatives and staff to make important decisions for them. The relatives are in contrast insecure about the residents' wishes and experience decision-making as a burden. The majority of the residents had not participated in advance care planning. None of the residents stated challenges connected to end-of-life care or mentioned the wish for euthanasia.

CONCLUSION

Although most residents seem to be satisfied with decision-making and end-of life care, there is a need for systematic advance care planning. Advance care planning could help to explore future wishes for care and ease decision-making for the relatives, physicians, and staff and should be offered to all cognitively able nursing homes residents.

Evaluating the systematic implementation of the 'Let Me Decide' advance care planning programme in long term care through focus groups: staff perspectives

BACKGROUND

The 'Let Me Decide' Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes.

METHODS

Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis.

RESULTS

Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff.

DISCUSSION

A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict.

CONCLUSION

The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.

Nurses' views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies

AIMS AND OBJECTIVES

To explore nurses' views regarding implementing advance care planning for older people.

BACKGROUND

Advance care planning is recommended as a way for older people to discuss their future care with family members and health professionals. Nurses play key roles in the process of advance care planning, including ensuring that patients are informed of their rights and that decisions are known to, and respected by, the health care team. Thus, understanding of nurses' experiences and perspectives regarding implementing advance care planning for older people is a significant topic for review.

DESIGN

Qualitative meta-synthesis.

METHODS

Four databases including CINAHL plus, Medline [EBSCOhost], EMBASE, and PsycINFO were searched, and 1844 articles were initially screened. Finally, 18 articles were critically appraised and a thematic synthesis was undertaken.

RESULTS

Four themes were identified regarding implementation of advance care planning: perceived disadvantages and advantages of advance directives; nurses' responsibility and roles; facilitators and barriers; and nurses' needs and recommendations. Nurses felt that advance directives provided more advantages than disadvantages. Nurses generally believed that they were well positioned to engage in advance care planning conversations. Nurses perceived barriers relating to older people, families, environment, time, culture, cost, language and knowledge of health care teams with regard to advance care planning. In nurses' needs, education and support were highlighted.

CONCLUSIONS

This study provides useful knowledge for implementing advance care planning through illustrating nurses' experiences and perspectives. The results showed that nurses were more concerned about barriers in relation to working environment, teamwork, time and knowledge of health care team members than older people's characteristics, when implementing advance care planning.

RELEVANCE TO CLINICAL PRACTICE

The findings provide nurses and administrators with information to develop related policies and education. Additionally, the appointment of nurses to formal roles related to advance care planning is appropriate and warranted.

Evaluation of an advance care planning education programme for nursing homes: A Longitudinal study

PURPOSE

To evaluate the success of a programme of Advance Care Planning education for nursing homes by examining the effect on staff knowledge, Advance Care Planning practice within the home and end-of-life hospital admission rates.

METHOD

Three longitudinal questionnaires assessing staff knowledge, Advance Care Planning Practice and hospital deaths completed before and after the initiation of the Advance Care Planning education programme by homes that had completed the training and those yet to undergo the training.

RESULTS

Superior Advance Care Planning knowledge was evident in those staff that had completed the training. There was an increase of 85% in the number of Advance Care Plans completed in the training homes and an overall reduction in hospital deaths of 25% for residents from training homes.

CONCLUSION

A programme of Advance Care Planning education for nursing homes is successful in improving nursing home staff knowledge, increasing Advance Care Planning practice and reducing hospital deaths.

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

BACKGROUND

Care in nursing homes (NHs) often overlooks individual values and preferences. Residents' voices are critical to discussions about preferences, yet there remains limited research on conversations about the end of life (EOL) from the perspective of older adults who reside in NHs.

OBJECTIVE

The aim of this study was to describe the communication, content and process, related to EOL conversations among residents, family, and staff.

METHODS

We used semistructured interviews in this qualitative, descriptive study to describe conversations about EOL preferences. We examined participants' conversation, when it occurred, and what was discussed. We queried about barriers to and facilitators in discussing EOL care in the NH setting. We interviewed residents (n=16), family (n=12), and interdisciplinary staff (n=10) from four NHs.

RESULTS

The overarching theme—missed conversations—describes EOL-related communication. Residents, families, and staff rarely talked about EOL care preferences, nor did they pass along information about preferences or initiate conversations about EOL care with each other. Three categories explained missed conversations: inquiry ("No one asked"); assumptions (presence of an advance directive [AD], "They know me"); and conveying (lack of conveying information or wishes). Existing barriers and lacking facilitators resulted in missed opportunities to hold conversations about EOL preferences.

CONCLUSIONS

Not all residents wanted to have conversations, but many wanted to be asked about their preferences. Missed conversations may adversely affect the quality of EOL care. Conversations with residents can be initiated by asking residents who they would like involved in the conversation and drawing upon the experience of others.

The effect of using high facilitation when implementing the Gold Standards Framework in Care Homes programme: a cluster randomised controlled trial

BACKGROUND

The provision of quality end-of-life care is increasingly on the national agenda in many countries. In the United Kingdom, the Gold Standards Framework for Care Homes programme has been promoted as a national framework for improving end-of-life care. While its implementation is recommended, there are no national guidelines for facilitators to follow to undertake this role.

AIM

It was hypothesised that action learning alongside high facilitation when implementing the Gold Standards Framework for Care Homes programme will result in a reduced proportion of hospital deaths for residents and improvement in the care home staff ability to facilitate good end-of-life care.

DESIGN

A cluster randomised controlled trial where 24 nursing homes received high facilitation to enable them to implement the Gold Standards Framework for Care Homes programme. The managers of 12 nursing homes additionally took part in action learning sets. A third group (14 nursing homes) received the 'standard' Gold Standards Framework for Care Homes facilitation available in their locality.

SETTING/PARTICIPANTS

In total, 38 nursing homes providing care for frail older people, their deceased residents and their nurse managers.

RESULTS

A greater proportion of residents died in those nursing homes receiving high facilitation and action learning but not significantly so. There was a significant association between the level of facilitation and nursing homes completing the Gold Standards Framework for Care Homes programme through to accreditation. Year-on-year change occurred across all outcome measures.

CONCLUSION

There is a danger that without national guidelines, facilitation of the Gold Standards Framework for Care Homes programme will vary and consequently so will its implementation. The nurse manager of a care home must be actively engaged when implementing the Gold Standards Framework for Care Homes programme.