The challenges in adopting care pathways for the dying for use in care homes

An increasing number of older people are requiring palliative care within the care home setting. There are currently a number of initiatives that are generally gaining approval and being implemented within health care in general with the goal of improving standards of palliative care. These are the Integrated Care Pathway for the dying person, the Gold Standards Framework and the Preferred Place of Care document. The Liverpool Care Pathway is being used across a wide range of care settings to improve care in the last 24–48 hours of life and is being implemented in care homes as part of a national rollout programme. This article aims to explore some of the issues associated with the use of the care pathways in care homes, particularly without the input of additional resources and support for the care homes. It also questions the appropriateness of the pathway in its current format without further work on the specific palliative care needs of the residents dying in care homes.     

Sheltered housing compared to independent housing in the community

Background:  With elderly people desiring to live independently as long as possible, traditional homes for the elderly are increasingly being transformed into sheltered accommodations. In order to assess the importance of housing for frail elderly people, elderly people at risk for institutionalization were studied in two living conditions: sheltered accommodation and living independently in the community.
Methods:  A total of 317 elderly people at risk for institutionalization [91 men and 240 women, mean age = 83.3 (SD = 6.0)] were interviewed using a structured questionnaire with questions regarding home care and social service use, quality of life, subjective well-being, life satisfaction, autonomy, functional status, feelings of insecurity and loneliness.
Results:  Exactly 56.5% of the respondents were living in sheltered accommodation (n = 179) and 43.5% (n = 138) were living in regular houses. Although both groups were similar in demographic details and functional status, those in sheltered accommodation had a higher perceived autonomy, sense of security and quality of life. No differences were found with regard to subjective well-being or feelings of loneliness. Elderly people in regular houses needed more hours of housekeeping assistance. Those in sheltered accommodation participated more frequently in services like social activities and social restaurants, but made less use of day care facilities.
Conclusions:  Affordable, decent and suitable noninstitutional housing with service provision play a vital role in the lives of elderly people. Compared with independent living in the community, sheltered accommodations provide added value. Sheltered housing should therefore be an integral part of long-term care policy.     

Dimensions of quality in long-term care facilities in Taiwan

AIM: This article presents the results of a qualitative study designed to explore the perceptions of Taiwanese elders about the quality of their care while in residence at a long-term care facility. BACKGROUND: As the population of elders in Taiwan is increasing rapidly, quality long-term care has become both a necessity and social responsibility. Research related to quality of care has focused on structure, process and outcomes as well as perceptions of quality of care and life satisfaction. Few authors have considered residents' perspectives within a cultural context. METHOD: A convenience sample of 22 residents, aged between 61 and 86 years and living in four Taiwanese care facilities, participated in semi-structured interviews. The data were generated during 2001/2002 and were analysed using content analysis. RESULTS: Six key dimensions of quality care were elicited. The dimensions were: a caring attitude, respect for individual differences, emotional support, social interaction, a supportive environment, and accessible care. These dimensions are discussed within a cultural context supportive of family connectedness and filial piety, values underpinning care expectations of elders. CONCLUSIONS: The findings provide a foundation for increased understanding of the perceived gaps between residents' aspirations about quality care and priorities identified in other studies. Additional studies based on these data are planned in order to generate a culturally relevant, psychometrically sound resident assessment tool to evaluate the quality of care from a resident perspective in long-term care facilities in Taiwan.     

人文关怀在优质护理服务工作中的应用

目的探讨人文关怀在优质护理服务中的运用,强化护理责任感、落实基础护理,提高护理质量,提高患者满意度。方法通过营造良好的病区环境,增强护士综合素质和主动服务的意识,夯实基础护理,提供安全的护理,实施出院后的延续护理等措施,为患者提供优质护理。结果人文关怀在优质护理服务中的运用,切实提高了护士主动服务的意识,患者满意度和护理质量得到了提高,护理纠纷减少,患者满意度由85.77%提高到97.50%(P<0.01)。结论人文关怀在优质护理服务活动中,提升了护士与患者主动沟通的能力,促进患者的恢复,达到真正意义上的护患和谐、医患和谐和社会的和谐。     

ICUs worldwide: an overview of critical care medicine in South Africa

South Africa has undergone rapid changes in the political and social arenas since 1994. With new policy-makers in the Department of Health, the distribution of health care resources are being rationalised and redirected to benefit the majority of the previously disadvantaged population of the country. The role and rationalisation of intensive care medicine has to be re-evaluated to ascertain that it is at a level appropriate for a developing country. Despite progress made, the subspecialty of intensive care medicine faces challenges from changing disease patterns and from lack of human and financial resources as these are redirected to primary health care and other priorities facing the country.     

Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners

Context

Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe.

Objectives

To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors.

Methods

A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present.

Results

Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4-6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6-4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7-4.1), died of cancer (OR 1.46; 95% CI 1.1-2.0), or died at home (OR 2.16; 95% CI 1.5-3.0).

Conclusion

In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.     

无缝隙护理在优质护理服务中的应用

目的 探讨无缝隙护理在优质护理服务中的应用,旨在为患者提供更人性化的护理,进而提高患者的满意度.方法 通过弹性排班,实行对患者包干到人的工作制度,加强护理的责任心,提高工作积极性.结果患者满意度较改革前提高8.2%,护理工作质量明显提高,护患关系更加和谐.结论 开展无缝隙护理是提供优质护理服务的重要手段,强调以患者为中心的整体护理理念,提高护理服务质量,提升医院的核心竞争力.     

Negotiations about helpfulness--the relationship between formal and informal care in home care arrangements

Scand J Caring Sci; 2011; 25; 706–715 Negotiations about helpfulness – the relationship between formal and informal care in home care arrangements Background: Informal caregiving by family members is the most common way of caring for sick people at home. However, the number of care arrangements, in which both formal (nurses) and informal (family members) caregivers are involved, is considerable and increasing. Despite implicit assumptions in research that the involvement of nurses in home care arrangements is inherently beneficial, there is evidence that their involvement may have a destabilising effect. Aims: The purpose of this study was to investigate the relationship between nurses and family caregivers and its impact on the actual care that is provided. Method: Eighty‐eight interviews with family caregivers (n = 57) and nurses (n = 31) were conducted in Germany and analysed according to the Grounded Theory methodology. Findings: The relationship between formal and informal care is an encounter of two quite different perspectives that is focused on a negotiation process about caregiving work and the helpfulness of the actions taken and the interventions used. For family caregivers, it is determined by the goal of facilitating work and care for their sick family member. The nurses’ work is characterised by a process of shaping different realities in different homes. The results reveal the processes that lead to the involvement of nurses into home care arrangements and offer a deeper understanding of the negotiation processes between formal and informal caregivers. Conclusions: To provide sufficient support in home care, nurses need the ability to engage in negotiation processes that take the whole home care arrangement into account. Developmental work is needed to design services that are helpful for family caregivers.     

Factors in care management affecting client outcomes in home care

The purpose of the present study was to identify which factors in care management affect client outcomes. We performed path analysis using care management processes as independent variables, and client outcomes measures as dependent variables. Client outcomes were measured by improvement in care items and Functional Independence Measure (FIM) scores in 170 clients, and client satisfaction in 97 clients. Improvement in care items was significantly related to the amount of service. Deterioration of the functional independence level was significantly related to the amount of service and lower implementation of monitoring. Higher implementation of evaluation raised client satisfaction. It is important for care managers to develop a care plan based on the necessary amount of service and to perform monitoring. A sufficient amount of service in the care plan and higher implementation of monitoring and evaluation are the three factors in care management affecting client outcomes.     

A Profile of Freestanding Emergency Departments in the United States, 2007

Background

Freestanding Emergency Departments (FSEDs) have emerged as an alternative to traditional hospital-based emergency care.

Study Objective

We sought to determine the number, basic types, distribution, and characteristics of United States (US) FSEDs in 2007.

Methods

Combining data from the 2007 National Emergency Department Inventory-USA database, the 2007 American Hospital Association Annual Survey of Hospitals, Internet searches, and telephone calls, we established an inventory of FSEDs. We define FSEDs as emergency care facilities physically distinct from a hospital. FSEDs include “satellite” Emergency Departments (EDs), which are owned by a parent hospital, and “autonomous” EDs, which lack such an affiliation.

Results

We identified 80 FSEDs operating in 2007, representing 1.6% of all US EDs; 73 (91%) in 20 states were satellite EDs, and seven (9%) in three states were autonomous EDs. Most FSEDs (92%; 95% confidence interval 83–97%) were located in urban areas, which is considerably higher than the proportion for hospital-based EDs (58%). The median distance from a satellite ED to a parent hospital ED was 10.6 miles. In 2007, FSED annual visit volumes ranged from 700 to 56,545 visits. The 2007 median visit volume was 18,769 (interquartile range 11,106–23,504; n = 52). This value did not vary by geographic region and is almost identical to the 2007 median visit volume for hospital-based EDs (18,776 visits).

Conclusions

FSEDs represent <2% of US EDs, with satellite EDs comprising a majority of all FSEDs. Most (92%) FSEDs are located in urban areas.     

Patient satisfaction and outcome using emergency care practitioners in New Zealand

Objective: A patient satisfaction survey was undertaken in the Kapiti District of the Wellington Region to ascertain patients' experience and opinions of New Zealand's first extended care paramedic (ECP) service before consideration is given to extending it to other locations within the region. Patient outcomes were also analysed for 1 week following ECP care. Methods: One hundred patients, 50 attended by ECPs and 50 by standard emergency ambulance service paramedics, were interviewed by an independent assessor, either in person or by phone according to patient preference. The questionnaire was aimed at comparing the experience of both groups of patients, dividing them into those treated at home and those transferred to the ED. ED and general practice records were then reviewed to determine whether the ECP‐treated patients attended either facility within 7 days and why. Results: Patients were very satisfied with their experience of both groups of paramedics but expressed a clear desire to be treated at home if possible. Of the 50 ECP‐treated patients, 11 were transferred directly to the ED. Only one clinical complication arose over the next 7 days in those treated in the community: a seizure in a patient with refractory epilepsy. Conclusion: The avoidance of unnecessary transfers to hospital is beneficial to patients, the ambulance service and the ED. This study demonstrates that patients are very satisfied with their assessment and treatment by ECPs, endorsing the proposal that the scheme should be extended across the Wellington Region, and perhaps New Zealand.     

Children in foster care: a vulnerable population at risk.

TOPIC: Nationally, 542,000 children are in foster care. Many of these children have prior histories of maltreatment such as abuse and neglect, with neglect being the most common form of maltreatment and the reason for many children requiring foster care services. Painful experiences associated with maltreatment and the trauma of being removed from one's parents (foster care) may affect the developmental and mental health of children. PURPOSE: This paper synthesizes the experiences associated with foster care and reveals foster care outcomes obtained through a literature search of published research. Specifically, the notions of oppression and domination defined by Young (1990) experienced by children in foster are explored. SOURCES: Review of the literature and clinical practice. CONCLUSIONS: Most children in foster care, if not all, experience feelings of confusion, fear, apprehension of the unknown, loss, sadness, anxiety, and stress. Such feelings and experiences must be addressed and treated early to prevent or decrease poor developmental and mental health outcomes that ultimately affect a child's educational experience and the quality of adulthood. Systemic orientation for all children entering foster care is proposed as a preventative intervention that addresses associated experiences of children in foster care.     

End-of-life care pathways in acute and hospice care: an integrative review

ContextOver the past decade, there has been widespread adoption of end-of-life care pathways as a tool to better manage care of the dying in a variety of care settings. The adoption of various end-of-life care pathways has occurred despite lack of robust evidence for their use.ObjectivesThis integrative review identified published studies evaluating the impact of an end-of-life care pathway in the acute and hospice care setting from January 1996 to April 2010.MethodsA search of the electronic databases Scopus and Cumulative Index of Nursing and Allied Health Literature as well as Medline and the World Wide Web were undertaken. This search used Medical Subject Headings key words including “end-of-life care,” “dying,” “palliative care,” “pathways,” “acute care,” and “evaluation.” Articles were reviewed by two authors using a critical appraisal tool.ResultsThe search revealed 638 articles. Of these, 26 articles met the inclusion criteria for this integrative review. No randomized controlled trials were reported. The majority of these articles reported baseline and post implementation pathway chart audit data, whereas a smaller number were local, national, or international benchmarking studies. Most of the studies emerged from the United Kingdom, with a smaller number from the United States, The Netherlands, and Australia.ConclusionExisting data demonstrate the utility of the end-of-life pathway in improving care of the dying. The absence of randomized controlled trial data, however, precludes definitive recommendations and underscores the importance of ongoing research.     

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

Objective To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.Design and setting Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.Patients 118,199 adult admissions to ICUs.Measurements and results The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7–96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.Conclusions Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.All work was completed at the Intensive Care National Audit & Research Centre, which also provided financial support