Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers

End-of-life conversations for the older person: A concept analysis

AIM

The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person.

DESIGN

Walker and Avant's eight step approach to Concept Analysis.

DATA SOURCES

Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis.

RESULTS

The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner.

CONCLUSIONS

End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

BACKGROUND

Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions.

METHODS

This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis.

DISCUSSION

The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning

OBJECTIVE

Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families.

DESIGN

Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts.

SETTING AND PARTICIPANTS

A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP.

METHODS

Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis.

RESULTS

Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises.

CONCLUSION AND IMPLICATIONS

Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.

Implementation of Advance Care Planning in Norway

Advance Care Planning has a relatively short history in the Norwegian health care services. This article gives an overview of advance care planning research and its implementation in the health care services in Norway. Advance care planning has received increased attention from policymakers and the health care services. Research projects have been performed, and several are on-going. Implementation has largely treated advance care planning as a complex intervention, with a whole-system approach that puts emphasis on the conversation and patient activation. Advance directives have a peripheral role in this context.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study

BACKGROUND

Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.

METHODS

After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.

RESULTS

We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.

CONCLUSIONS

Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

A multidisciplinary simulation programme to improve advance care planning skills and engagement across primary and secondary care

BACKGROUND

In the context of an ageing population, many healthcare professionals have limited experience and confidence in having necessary advance care planning (ACP) conversations.

METHODS

We conducted nine half-day simulation sessions, using professional actors. One-hundred and thirty-two participants attended from multidisciplinary backgrounds across primary and secondary care.

RESULTS

Following the course, 90.2% felt confident or very confident initiating conversations, compared with 14.4% beforehand. Understanding of when ACP is appropriate also increased from 70% to 100%. Post-course, 98% of participants stated that they would be more likely to initiate an ACP. Three months later, 86% had a sustained change in practice. All participants said they would recommend this simulation course and multidisciplinary approach.

CONCLUSION

Multidisciplinary simulation training is an effective way to teach ACP to doctors, nurses and allied healthcare professionals. The simulation was shown to improve participant understanding, confidence and reduce barriers to discussions, both immediately and 3 months later.

Palliative care in the community - the role of the resource nurse, a qualitative study

BACKGROUND

Approaches involving resource nurses have been used in several fields of practice to enhance quality of care. A literature review reveals limited research on the role of the resource nurse in palliative care in the community.

AIM

To explore experiences related to the role of the resource nurse in palliative care in the setting of nursing homes in Norway.

DESIGN

The study has an explorative design with a qualitative approach.

METHODS

Two semi structured group interviews were conducted. Five resource nurses participated in the first interview, two resource nurses participated in the last interview. The group interviews were audiotaped, transcribed verbatim and analysed with systematic text condensation.

RESULTS

The resource nurses wish to promote high-quality palliative care. They are skilled palliative nurses working clinically, and they use their experience and knowledge to talk about and demonstrate good practice. By conveying knowledge and being role models, they bolster their colleagues' confidence and skills in palliative care and contribute to a shared view of quality. They can potentially play an important role in facilitating reflection and collaboration in the palliative care team. However, the resource nurse's function is affected by interpersonal, managerial and organisational factors.

CONCLUSION

The resource nurse most important tool in promoting high-quality palliative care may be to support their colleagues being a role model, and sharing knowledge and experience. The resource nurses play an important role in facilitating reflection and collaboration in the palliative care team and may contribute to ethical awareness and proper dialogues about end of life issues.

Knowledge, attitude and practice of advance care planning among nursing interns: A mixed-methods approach

AIM

To investigate the knowledge, attitudes and practice of advance care planning and confirm their influencing factors among nursing interns in China.

BACKGROUND

Due to a lack of standardized courses on advance care planning (ACP) in China, nursing interns do not possess the knowledge of ACP and cannot apply it to clinical practice.

DESIGN

A convergent parallel mixed-methods design.

METHODS

382 nursing interns aged > 18 years were recruited using convenience sampling. Quantitative data were collected using the General Demographic Characteristics Questionnaire and the Advance Care Planning Knowledge, Attitude and Practice Questionnaire. Thirteen nursing interns were drawn from the quantitative phase and their interviews were thematically analyzed.

RESULTS

The ACP attitudes and practice scores of nursing students were 48.85 ± 6.39 and 32.23 ± 4.58, respectively, with a high level, while their ACP knowledge score was 6.89 ± 2.70, with a medium level. The significant promotive factors included positive attitude toward death and the nursing major and experience in clinical rescues and palliative care training; The key hindrance factors included the lack of ACP education and the limitations of the working environment.

CONCLUSIONS

The study highlighted the importance of delivering systematic palliative care training and integrating the practice of ACP into routine nursing practice. Doing this can help expand advance care planning knowledge, establish positive attitudes and meet the practical needs of nursing interns for their ACP clinical practice.

Positive attitudes to advance care planning - a Norwegian general population survey

Background

Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning.

Methods

An electronic survey to a nationally representative web panel of Norwegian adults.

Results

From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness.

Conclusions

Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.

Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study

BACKGROUND AND AIMS

Advance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014-2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP.

METHODS

Conversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient's medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation.

RESULTS

Fifty-one patients participated in ACP conversations (41-86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice.

CONCLUSIONS

Patients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.

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.

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 home residents with cognitive impairment can participate in advance care planning: A qualitative study

AIMS

To describe advance care planning in nursing homes when residents with cognitive impairment and/or their next of kin participated and identify associated challenges.

DESIGN

A qualitative study of nine advance care planning conversations in four Norwegian nursing home wards. During the implementation of advance care planning, we purposively sampled residents with cognitive impairment, their next of kin and healthcare personnel. The implementation followed a "whole-ward" approach aimed at involving the whole ward in fostering an inclusive, holistic advance care planning discussion. Involving as many residents as possible, preferably together with their next of kin, were central.

METHODS

From observed and audio-recorded advance care planning conversations that took place from November 2015 to June 2016, we conducted a thematic analysis of the transcripts and field notes. Reporting adhered to the COREQ guidelines.

RESULTS

Residents actively relayed their preferences regarding healthcare and end-of-life issues, despite the cognitive impairment. Next of kin provided constructive support and conversations were largely resident-focused. However, involving residents was also challenging, findings included: residents' preferences were often vague, relevant medical information from healthcare personnel lacked and the next of kin were sometimes unaware of the resident's previously held preferences. Moreover, residents tended to focus more on the past and present than the future end-of-life care.

CONCLUSIONS

Residents with cognitive impairment can participate actively and meaningfully in advance care planning, if the healthcare personnel actively listens. However, several challenges can arise. Supported decision-making can improve communication and resident involvement, reinforcing a relational understanding of autonomy.

IMPACT

Persons with cognitive impairment should be invited to participate in advance care planning. Their participation may make its benefits and more person-centred care attainable to persons that are often not involved. Successful involvement of persons with cognitive impairment in advance care planning may rely on robust implementation.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Views of advance care planning in caregivers of older hospitalised patients following an emergency admission: A qualitative study

This study explores the views of advance care planning in caregivers of older hospitalised patients following an emergency admission. Semi-structured interviews were conducted with eight carers, mostly with a personal relationship to the older patient. Thematic analysis generated three themes: (1) working with uncertainty – it all sounds very fine. . . what is the reality?, (2) supporting the older person – you have to look at it on an individual basis and (3) enabling the process – when you do it properly. The belief that advance care planning can support older individuals and scepticism whether advance care planning can be enabled among social and healthcare challenges are discussed.

Advance care planning: the who, what, when, where and why

Advance care planning is an opportunity for patients to express their priorities for future care. NHS England has outlined a commitment to end-of-life care, advocating a shift towards more patient-centred care. The NHS is encouraging the workforce to engage patients in conversations about what is important to them, shifting the focus from 'what is wrong with you' to 'what matters to you'. Traditionally, this was seen as the doctor's role but this conversation can and should happen with the wider skilled medical workforce. The key to advance care planning is to have these conversations early on when patients have the capacity to discuss their preferences for care. Advance care planning can occur in any setting where the patient is comfortable to have the conversation, be that at home, in the GP surgery, in hospital or another setting. Patients with advance care plans are more likely to have their wishes respected, have fewer unwanted interventions, experience reduced transitions between care settings and are more likely to die in their preferred place of death. Healthcare professionals have a duty to offer advance care planning to patients nearing the last phase of life so that care can be delivered to honour individual needs at the end of life.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial

OBJECTIVE

To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment.

METHODS

This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate.

RESULTS

In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased.

CONCLUSION

Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach.

PRACTICE IMPLICATIONS

Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning.

TRIAL REGISTRATION

ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.