Concept analysis of good death in long term care residents

Cultural adaptation and validation of the Quality of Dying in Long-term Care (QoD-LTC and QoD-LTC-C) scales by caregivers in nursing homes

BACKGROUND

There is a lack of tools that can evaluate quality of dying in nursing homes from the perspective of deceased patients' caregivers. The aim of this study was to adapt and validate the caregivers' versions of the Quality of Dying in Long-Term Care (QoD-LTC) and Quality of Dying in Long-Term Care Complete (QoD-LTC-C) scales in the Spanish context.

METHODS

This was a cultural adaptation and validation study. The scales were translated from English to Spanish and vice versa, and 13 experts in end-of-life care participated in a two-round Delphi panel. Caregivers of 69 deceased residents from seven nursing homes in southern Spain completed both scales. Reliability, feasibility, and concurrent validity with global quality of dying perception and symptom burden (Edmonton Symptom Assessment Scale), were evaluated.

RESULTS

Spanish caregivers' version of the QoD-LTC scale showed good internal consistency for the total scale (α = 0.74) and each of its three factors, and good inter-rater reliability (ICC = 0.50) and test-retest reliability (ICC = 0.81). The Spanish QoD-LTC-C scale for caregivers showed good internal consistency for the total scale (α = 0.81) and for its component factors, and good test-retest reliability (ICC = 0.89) and inter-rater reliability (ICC = 0.66). Both scales correlated with family caregivers' global perception of deceased residents' quality of dying (r = 0.39; r = 0.32), but not with the ESAS score.

CONCLUSIONS

Both scales presented an adequate factorial structure, internal consistency, and reliability to assess caregivers' perception of the quality of dying in Spanish nursing homes.

Just and inclusive end-of-life decision-making for long-term care home residents with dementia: a qualitative study protocol

BACKGROUND

Many people living with dementia eventually require care services and spend the remainder of their lives in long-term care (LTC) homes. Yet, many residents with dementia do not receive coordinated, quality palliative care. The stigma associated with dementia leads to an assumption that people living in the advanced stages of dementia are unable to express their end-of-life needs. As a result, people with dementia have fewer choices and limited access to palliative care. The purpose of this paper is to describe the protocol for a qualitative study that explores end-of-life decision-making processes for LTC home residents with dementia.

METHODS/DESIGN

This study is informed by two theoretical concepts. First, it draws on a relational model of citizenship. The model recognizes the pre-reflective dimensions of agency as fundamental to being human (irrespective of cognitive impairment) and thereby necessitates that we cultivate an environment that supports these dimensions. This study also draws from Smith's critical feminist lens to foreground the influence of gender relations in decision-making processes towards palliative care goals for people with dementia and reveal the discursive mediums of power that legitimize and sanction social relations. This study employs a critical ethnographic methodology. Through data collection strategies of interview, observation, and document review, this study examines decision-making for LTC home residents with dementia and their paid (LTC home workers) and unpaid (family members) care partners.

DISCUSSION

This research will expose the embedded structures and organizational factors that shape relationships and interactions in decision-making. This study may reveal new ways to promote equitable decision-making towards palliative care goals for LTC home residents with dementia and their care partners and help to improve their access to palliative care.

Quality of dying among elderly people diagnosed with dementia in nursing homes: A mixed methods study

WHAT IS KNOWN ON THE SUBJECT

Nurses working at nursing homes can play a pivotal role in mental health as a high proportion of residents diagnosed with dementia are in these facilities. Many institutionalized residents diagnosed with dementia develop clinical complications and symptoms that reduce the quality of dying. A mixed-methods approach can help nurses with the difficult task of assessing the quality of dying among these residents and identify inconsistencies that cannot be found using scales alone, but no studies were found in this topic.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Through the Quality of dying in Long-Term Care Scale (QoD-LTC), nurses described symptom management, quality of care, and end-of-life appearance as adequate and end-of-life communication as lacking. Generally speaking, the scores on the scale were consistent with the data from semi-structured interviews conducted with nurses. In the semi-structured interviews, some of the concepts on the scale, including 'dignity', 'holistic' care, 'good relationships with healthcare professionals', and 'a peaceful death', are complex and not fully incorporated into nurses' practice in nursing homes when assessing residents diagnosed with dementia. This could be improved by using the SENSES Model or person-centred care frameworks. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is evidence of shortcomings among professionals in the correct use of concepts linked to psychological wellbeing, communication, therapeutic relationship, safety and participation, preservation of dignity, decision-making, and resident autonomy, which can be addressed using specific theoretical approaches developed in the field of mental health nursing.

ABSTRACT

Introduction The complex nature of end-of-life assessment of individuals diagnosed with dementia would benefit from a mixed-methods approach that simultaneously assess the perception and response of nurses to standardized tools. Aim/Question To examine nursing professionals' perceptions of the quality of dying among residents diagnosed with dementia using the Quality of Dying in Long-Term Care settings (QoD-LTC) questionnaire and to identify consistencies and inconsistencies in their narratives. Method Mixed-methods study using concurrent triangulation with data integration for results and interpretation. Nurses from eight nursing homes assessed 117 residents diagnosed with dementia who died in the previous 3 months using the QoD-LTC scale. After informed consent was obtained (nurses/caregivers), 17 semi-structured scale-based interviews were conducted. Results Symptom management, quality of care, and end-of-life appearance were found to be adequate, while end-of-life communication was deemed insufficient. The qualitative and quantitative data were consistent for most of the items on the QoD-LTC. Discussion Concepts such as dignity, holistic care, good relationships, and peaceful death are complex and not fully incorporated into professional practice. Implications for Practice The results highlight the need for greater involvement of mental health nurses as well as improved communication, training, and specific tools tailored to residents diagnosed with dementia.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

Exploring variables related to medical surrogate decision-making accuracy during the COVID-19 pandemic

OBJECTIVE

Surrogate medical decision making is common in the United States healthcare system. Variables that may influence surrogate decision making have been proposed. Little work has examined relations between these variables and outcomes of surrogate decision making. This study investigated whether surrogates' characteristics, including their knowledge of treatment options, and interpersonal factors predicted surrogates' accuracy and intervention selections. Specifically, predictor variables included: trust in the medical profession, trait-level anxiety, depression, anxiety about COVID-19, religiosity, perceived emotional support, understanding of treatment options, empathy, willingness to accept responsibility for medical decisions, reluctance to burden others, and perceived similarity between oneself and the patient.

METHODS

154 pairs of patients and their surrogates completed an online survey. Patients indicated preferred treatments in hypothetical decision scenarios. Surrogates indicated the treatment that they thought the patient would prefer.

RESULTS

When taken all together in a predictive model, the variables significantly predicted surrogates' accuracy, F (6) = 3.03, R² = .12, p = .008. Variables also predicted selection of intensive interventions, F (4) = 5.95, R² = .14, p = .00. Surrogates reporting greater anxiety about COVID-19 selected more intensive interventions.

CONCLUSIONS

Consistent with prior research, this study found that surrogates' characteristics influence the interventions they choose, with anxiety about COVID-19 having considerable bearing on their chosen interventions.

PRACTICE IMPLICATIONS

These findings can inform development of decision-making interventions to improve surrogates' accuracy. Providers may attend to variables highlighted by this study to support surrogates, particularly within the stressful context of COVID-19 and possible future pandemics.

What would it take to die well? A systematic review of systematic reviews on the conditions for a good death

The medicalisation of life under the influence of health-care systems, focused on curing diseases, has made dying well challenging. This systematic review identifies common themes from published systematic reviews about the conditions for a good death as a means to guide decisions around this universal event. MEDLINE, Embase, APA PsycInfo, and AMED were searched for citations with "good death" or "dying well" in their titles on Sept 23, 2020, and complemented with backward reference and forward citation screening with Google Scholar. Articles published in peer-reviewed journals in any language were included. Articles that focused on the identification of conditions for a good death and described how primary studies were sought and selected were also included. Data on general characteristics, quality, and themes were extracted independently. 13 of 275 potentially eligible reviews were included. Common themes were dying at the preferred place, relief from pain and psychological distress, emotional support from loved ones, autonomous treatment decision making, avoidance of futile life-prolonging interventions and of being a burden to others, right to assisted suicide or euthanasia, effective communication with professionals, and performance of rituals. No reviews specified the meaning or timing of death, connected themes, or prioritised them. Vague jargon was often used to describe complex concepts. Most conditions for a good death could be offered to most dying people, without costly medical infrastructure or specialised knowledge. Efforts to describe these conditions clearly, to identify whether there are exceptions or missing items, and whether they apply in non-dominant settings (ie, outstide institutional, affluent, anglophone, and Christian settings) are needed.

End-of-life care preferences among cancer patients in Southern Thailand: a university hospital-based cross-sectional survey

BACKGROUND

End-of-life care preferences may be highly individual, heterogenic, and variable according to culture and belief. This study aimed to explore preferences and factors associated with end-of-life care among Thai cancer patients. Its findings could help optimize the quality of life of palliative cancer patients.

METHODS

A cross-sectional study surveyed palliative cancer outpatients at Songklanagarind Hospital from August to November 2020. The questionnaires inquired about: (1) personal and demographic information, (2) experiences with end-of-life care for their relatives, and (3) end-of-life care preferences. To determine end-of life preferences, the data were analyzed using descriptive statistics. The data concerning patient demographics and end-of-life care preferences were compared using Fisher's exact test.

RESULTS

The majority of the 96 palliative cancer outpatients were female (65.6 %), and the overall mean age was 55.8 ± 11.6 years. More than half of them had an experience of observing someone die (68.8 %), and they were predominantly being conscious until the time of death (68.2 %). Most participants preferred receiving the full truth satisfied with the care their relatives had received in passing away at home surrounded by family (47.0 %) and regarding their illness (99.0 %), being free of uncomfortable symptoms (96.9 %), having their loved ones around (93.8 %), being mentally aware at the last hour (93.8 %), and having the sense of being meaningful in life (92.7 %). Their 3 most important end-of-life care wishes were receiving the full truth regarding their illness, disclosing the full truth regarding their illness to family members, and passing away at home.

CONCLUSIONS

In order to optimize the quality of life of palliative cancer patients, end-of-life care should ensure they receive the full truth regarding their illness, experience no distressing symptoms, remain mentally aware at the last hour of life, feel meaningful in life, and pass away comfortably with loved ones around.

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.

Cultural Adaptation and Validation of the Quality of Dying in Long-Term Care Scale (QoD-LTC) for Spanish Nursing Homes

BACKGROUND

There is a need for instruments that can evaluate the psychosocial quality of dying in nursing homes. The aim of this study was to adapt and validate the Quality of Dying in Long-Term Care scale (QoD-LTC) to the Spanish context.

METHODS

Descriptive cross-sectional study. Fourteen nurses from 7 facilities in southern Spain assessed 153 residents who died in the centers; validity, reliability, and feasibility were evaluated.

RESULTS

The Spanish version consists of 11 items with acceptable reliability (α = 0.681). Three factors model was validated by principal components analysis. A mean of 180.62 (SD = 86.66) seconds is needed to fill it in. An inter-observer 0.753 (95% CI: 0.391-0.900, p< 0.001) and intra-observer 0.855 (95% CI: 0.568-0.951 p = 0.001) reliability were observed. Weak correlation was observed; positive with mono-item question (0.322) and negative with Eastern Cooperative Oncology Group (ECOG) with a value of (-0.321) and Integrated Palliative outcome scale (IPOS) with a value of (-0.252).

CONCLUSIONS

The QoD-LTC scale presents an adequate factorial structure, internal consistency, and feasibility to evaluate psychosocial quality of dying in nursing homes. It can be used as a quality indicator.

Quality of end-of-life care of home-based care with or without palliative services for patients with advanced illnesses

Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05-0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.

Exploring a Nursing Home-Specific Interdisciplinary Approach: Toward Palliative Care for the Demented and Complex-Disabled Elderly

The number of elderly suffering from dementia and complex disabilities is gradually increasing in nursing homes, and they form a differentiated group that requires palliative care provided by practitioners in various disciplines from the time of their admission to improve the quality of their remaining lives. The purpose of this study was to explore an interdisciplinary care approach by nurses and related practitioners for the demented and complex-disabled elderly in nursing homes that focuses on palliative care based on an ethical point of view. A qualitative thematic analysis was conducted through in-depth interviews of 29 interdisciplinary practitioners working at 5 nursing homes. From them, 3 themes and 9 subthemes were extracted as the key results. First, practitioners set up cooperative care plans based on constantly tracking down clues to gradual functional deteriorations. Second, practitioners establish a cooperative committee to link residents and practitioners for responding to the subtle expressions of the elderly. Finally, practitioners maximize the opportunities for improving the quality of the elderly's remaining lives. These results can be the basis for the first prototype in developing interdisciplinary practical guidelines for nursing home-specific palliative care and can provide new insights for the practical care concept of palliative care.

Quality of life of older persons in nursing homes after the implementation of a knowledge-based palliative care intervention

BACKGROUND

The goals of palliative care are to relieve suffering and promote quality of life. Palliative care for older persons has been less prioritised than palliative care for younger people with cancer, which may lead to unnecessary suffering and decreased quality of life at the final stage of life.

AIM

To evaluate whether a palliative care intervention had any influence on the perceived quality of life of older persons (≥65 years).

METHODS

This study was conducted as a complex intervention performed with an experimental crossover design. The intervention was implemented in 20 nursing homes, with a six-month intervention period in each nursing home. Twenty-three older persons (≥65 years) in the intervention group and 29 in the control group were interviewed using the WHOQOL-BREF and WHOQOL-OLD questionnaires at both baseline and follow-up. The collected data were analysed using the Wilcoxon signed-rank test to compare paired data between baseline and follow-up.

RESULTS

In the intervention group, no statistically significant increases in quality of life were found. This result contrasted with the control group, which revealed statistically significant declines in quality of life at both the dimension and item levels. Accordingly, this study showed a trend of decreased health after nine months in both the intervention and control groups.

CONCLUSION

It is reasonable to believe that quality of life decreases with age as part of the natural course of the ageing process. However, it seems that the palliative care approach of the intervention prevented unnecessary quality of life decline by supporting sensory abilities, autonomy and social participation among older persons in nursing homes. From the ageing perspective, it may not be realistic to strive for an increased quality of life in older people living in nursing homes; maybe the goal should be to delay or prevent reduced quality of life. Based on this perspective, the intervention prevented decline in quality of life in nursing home residents.

IMPLICATIONS FOR PRACTICE

The high number of deaths shows the importance to identify palliative care needs in older persons at an early stage to prevent or delay deterioration of quality of life.

Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia

OBJECTIVES

Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying.

DESIGN

Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325.

SETTING

Twelve Australian care homes in Canberra, Australia.

PARTICIPANTS

A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018.

INTERVENTION

Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning.

MEASUREMENTS

This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney.

RESULTS

Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72).

CONCLUSION

The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.

Is the bereavement grief intensity of survivors linked with their perception of death quality?

Background:

Some people experience exceptionally severe bereavement grief, and this level of post-death grief could potentially be the result of a low quality dying process.

Aims:

A pilot study was conducted to determine if a relationship exists between perceived death quality and bereavement grief intensity.

Methods:

A questionnaire was developed and posted online for data on bereavement grief intensity, perceived death quality, and decedent and bereaved person characteristics. Data from 151 Canadian volunteers were analysed using bi-variate and multiple linear regression tests.

Findings:

Half had high levels of grief, and over half rated the death as more bad than good. Perceived death quality and post-death grief intensity were close to being negatively correlated.

Conclusion:

These findings indicate research is needed to explore possible connections between bereavement grief and the survivor's perceptions of whether a good or bad death took place. In the meantime, it is important for palliative care nurses to think of the quality of the dying process as being potentially very impactful on the people who will be left to grieve that death.

Predicting hospital transfers among nursing home residents in the last months of life

BACKGROUND

Concerns have been raised over the practice of transferring nursing home residents to hospital at their end of life.

OBJECTIVE

To examine the family and facility factors that may influence the decision to transfer nursing home residents to hospital in the last month of life.

RESEARCH DESIGN

Secondary data analysis includes a sample of 119 bereaved family members from 21 nursing homes located in Central Canada.

METHOD

A binary logistic regression analysis was conducted to explore the predictors for hospital transfers.

RESULTS

Terminal hospital transfers were common: 70% of nursing home residents were sent to hospitals in the last month of their life, and the likelihood of terminal hospital transfers increased by having an adult child as decision-maker (odds ratio (OR) = 5.03; 95% confidence interval (CI) = 1.6, 16; significance level/probability value (p) = 0.007) or having a lower family income (OR = 2.9; 95% CI =1.1, 2.9; p = 0.027). Discussion and implications: The identified predictors for terminal hospital transfers are helpful in targeting and developing interventions to improve end-of-life care. Particular emphasis should therefore be placed on targeting families with low income and children of the nursing home residents for educational initiatives such as advance care planning awareness, in order to prevent terminal hospital transfers. It is hoped that policy-makers and practitioners can start addressing the findings of this study to reduce terminal hospital transfers at end of life and promote quality end-of-life care in nursing homes.

Equal palliative care for patients with COPD? A nationwide register study

Background: Although chronic obstructive pulmonary disease (COPD) is a life-limiting disease with a significant symptom burden, the patients are more often referred to nursing homes (NH), than to specialist palliative care (SPC) at the end of life (EOL). This study aimed to compare patients with COPD in SPC with those in NH and to compare the care provided. Methods: A national register study was carried out where the Swedish National Airway Register and the Swedish Register of Palliative Care were merged. COPD patients who died in NHs or short-term facilities were included in the NH group (n = 415) and those who died in SPC were included in the SPC group (n = 355). Demographic and clinical variables were included from the Swedish National Airway Register and variables concerning EOL care from the Swedish Register of Palliative Care. Results: Symptom prevalence was similar in NHs and SPC, but symptom assessment (32% vs 20%), symptom relief medication (93-98% in SPC vs 74-90% in NH), EOL discussions (88% vs 66%), and bereavement support (94% vs 67%) were more likely in SPC (in all comparisons p < 0.001). Younger age and co-habiting increased the probability of dying in SPC (p < 0.001). Conclusion: Despite similar symptom prevalence, older persons are more likely to be referred to NHs. If applying a palliative care philosophy in NHs, routine symptom assessment and prescription of rescue medication for frequent symptoms, would be more likely. Promoting advance care planning and EOL discussions at an earlier stage would result in more prepared patients and families.