Telehealth Palliative Care Needs Rounds During a Pandemic

Older people living in care homes deserve access to specialist palliative care in their last months of life, and this has never been more important than during a global pandemic. Palliative Care Needs Rounds facilitated by nurse practitioners are cost-effective, reduce avoidable hospital transfers, improve quality of death and dying, and increase the capacity of staff to recognize and plan for care for dying residents in care homes. Conducting Palliative Care Needs Rounds via telehealth increases access to specialist palliative care while reducing the risk of coronavirus disease 2019 transmission.     

End-of-life care for nursing home residents dying from cancer in Nova Scotia,Canada, 2000–2003

INTRODUCTION: With our population aging, an increasing proportion of cancer deaths will occur in nursing homes, yet little is known about their end-of-life care. This paper identifies associations between residing in a nursing home and end-of-life palliative cancer care, controlling for demographic factors. METHODS: For this population-based study, a data file was created by linking individual-level data from the Nova Scotia Cancer Centre Oncology Patient Information System, Vital Statistics, and the Halifax and Cape Breton Palliative Care Programs for all persons 65 years and over dying of cancer from 2000 to 2003. Multivariate logistic regression was used to compare nursing home residents to nonresidents. RESULTS: Among the 7,587 subjects, 1,008 (13.3%) were nursing home residents. Nursing home residents were more likely to be female [adjusted odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.7], older (for > or = 90 vs 65-69 years OR 5.4, CI 4.1-7.0), rural (OR 1.5, CI 1.2-1.8), have only a death certificate cancer diagnosis (OR 4.2, CI 2.8-6.3), and die out of hospital (OR 8.5, CI 7.2-10.0). Nursing home residents were less likely to receive palliative radiation (OR 0.6, CI 0.4-0.7), medical oncology consultation (OR 0.2, CI 0.1-0.4), and palliative care program enrollment (Halifax OR 0.2, CI 0.2-0.3; Cape Breton OR 0.4, CI 0.3-0.7). CONCLUSION: Demographic characteristics and end-of-life services differ between those residing and those not residing in nursing homes. These inequalities may or may not reflect inequities in access to quality end-of-life care.     

The Supportive Hospice and Aged Residential Exchange (SHARE) programme in New Zealand

Research indicates that staff in aged residential care may be unprepared for their role in palliative care provision. In collaboration with a local hospice, the project piloted an innovative problem-based experiential learning intervention Supportive Hospice and Aged Residential Exchange (SHARE) to enhance aged residential care staff palliative care skills. The aim was to explore the impact of SHARE for staff. SHARE was implemented in two aged residential care facilities in one urban centre for six months. Measurement of the impact of the intervention consisted of 1) pre-test-post-test questionnaires (n = 27) to assess changes in staff confidence in palliative care delivery 2) Eleven post-intervention interviews to describe staff perceptions of SHARE. Results from the SHARE pilot indicate that the intervention overall is seen as a success, especially in relation to advanced care planning documentation. Relationships between hospice and facility staff, and consequently facility staff and residents are seen as the key to the success of the project. Staff survey results indicated increased confidence in palliative care delivery and decreased depression. Key lessons learnt from for the development of any palliative care intervention within aged residential care include the importance of reciprocal learning, as well as the necessity of a strong partnership with key stakeholders.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Editor's Page

Abstract

Aim

To explore the views of general practitioners (GPs) regarding the involvement of the practice nurse (PN) in supporting older people with heart failure (HF) throughout the disease trajectory and identify specific implications for initiating advance care planning and improving end-of-life care.

Methods

Thirty GPs in a large urban area of New Zealand (NZ) participated in in-depth qualitative interviews. The interviews were recorded and transcribed verbatim. Data were entered into Nvivo software and were analysed thematically.

Results

While the GPs' experiences of working with the PN as contributor to the management of older patients with HF were positive overall, very minimal involvement of the PN in palliative and end-of-life care management was identified. However, significant potential for expansion was identified, particularly in the areas PNs are currently involved in, namely communication, education, and coordinating services, all of which are considered essential to effective palliative and end-of-life care.

Conclusion

The views of GPs are important as they employ PNs in NZ and are central to the ways in which the PN role can be developed in the future to improve services for older people with HF throughout the disease trajectory. Our study indicates that there is significant potential to expand the role of the PN throughout the HF disease trajectory, a development which could address some of the current gaps in palliative and end-of-life care management for these patients. Further research is required to develop and evaluate a model which optimizes the PN role throughout the disease trajectory of people with HF.     

Development and implementation of a pediatric palliative care program

Palliative care, long-used in the adult setting, is new to the pediatric setting. Research indicates that palliative care reduces length of stay and use of aggressive end-of-life interventions, improves quality of life, and provides hope. It balances provision of coordinated care with building of family memories and preparation for the child's death with celebration of the child's life. We advocate implementation of pediatric palliative care in any hospital that cares for children. This article provides a model outlining critical steps and considerations for establishing a successful pediatric palliative care program.     

Attitudes towards end-of-life care in a geriatric hospital in Japan

Nursing and medical staff attitudes toward end-of-life care at a private, not-for-profit geriatric hospital in Japan were measured as part of a larger intervention study to develop a palliative care programme. The intervention consisted of focus groups, education with pre- and post-testing, and attitude/belief surveys. All the medical staff (n = 8) and 99% (n = 97) of the nursing staff participated. Nursing staff overwhelmingly agreed that a palliative care programme would improve end-of-life care (94.6%) and that nurses should be more involved in discussing treatment options with families (85.7%). Of the nursing staff, 88.7% did not agree that doctors currently spend enough time discussing care plans with patients/families. The main barriers to improving end-of-life care perceived by the nursing staff were the treatment-oriented attitude of the doctors and their limited communication skills. The main barriers perceived by doctors were the lack of alternatives to their medical approach and legal concerns. The findings suggest that improving doctor/nurse communication would facilitate the development of a palliative care programme at this hospital.     

Healthcare professionals’ values about and experience with facilitating end-of-life care in the adult intensive care unit

ObjectivesTo evaluate values and experience with facilitating end-of-life care among intensive care professionals (registered nurses, medical practitioners and social workers) to determine perceived education and support needs.Research designUsing a cross-sectional study design, 96 professionals completed a survey on knowledge, preparedness, patient and family preferences, organisational culture, resources, palliative values, emotional support, and care planning in providing end-of-life care.SettingGeneral adult intensive care unit at a tertiary referral hospital.ResultsCompared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK (p = 0.02), lower availability of counselling services (p = 0.01), perceived insufficient time to spend with families (p = 0.01), less in-service education for end-of-life topics (p = 0.002) and symptom management (p = 0.02). Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios (p = 0.01).ConclusionFindings inform strategies for practice development to prepare and support healthcare professionals to provide end-of-life care in the intensive care setting. Professionals reporting similar palliative care values and inclusion of patient and family preferences in care planning is an important foundation for planning interprofessional education and support with opportunities for professionals to share experiences and strengths.     

Usefulness,feasibility and face validity of the interRAI Palliative Care instrument according to care professionals in nursing homes: A qualitative study

BackgroundNursing homes are important locations for palliative care. High quality palliative care requires an evaluation of the different care needs of the nursing home residents. The interRAI Palliative Care instrument is a comprehensive assessment that evaluates the needs and preferences of adults receiving palliative care.ObjectivesThis study aims to evaluate the usefulness, feasibility and face validity of the interRAI Palliative Care instrument.DesignA qualitative study was conducted, based on the abductive reasoning approach.SettingFifteen nursing homes in Flanders (Belgium).ParticipantsCalls for participation were sent out by four umbrella organizations of Flemish nursing homes (Belgium) and at a national conference for nursing home staff. Nineteen care professionals (nurses, certified nursing assistants, psychologists, physiotherapists, quality coordinators and directors) of 15 nursing homes voluntarily agreed to participate in the study.MethodsDuring one year, care professionals evaluated the needs and preferences of all nursing home residents receiving palliative care by means of the interRAI Palliative Care instrument. Data on the usefulness, feasibility and face validity of the interRAI Palliative Care instrument were derived from notes, semi-structured interviews and focus groups with participating care professionals and were thematically analyzed and synthesized. Data were gathered between December 2013 and March 2015.ResultsIn general, the interRAI Palliative Care (interRAI PC instrument) is a useful instrument according to care professionals in nursing homes. However, care professionals made a series of recommendations in order to optimize the usefulness of the instrument. The interRAI PC instrument is not always feasible to complete because of organizational reasons. Furthermore, the face validity of the instrument could be improved since certain items are incomplete, lacking, redundant or too complex.ConclusionsFindings highlight the importance of adapting the content of the interRAI Palliative Care instrument for use in nursing homes. Furthermore, the use of the instrument should be integrated in the organization of daily care routines in the nursing homes. Tackling the critical remarks of care professionals will help to optimize the interRAI Palliative Care instrument and hence support palliative care of high quality in nursing homes.     

Long-term care nurses' knowledge of end-of-life care

Long-term care (LTC) facilities usually contract with hospice agencies to provide palliative (comfort) care to their terminally ill residents, yet only 1% of nursing home residents enroll in hospice care. Integrating hospice services with nursing home services presents many challenges. One of the most critical challenges is the lack of education in palliative care among physicians, licensed nurses, and certified nursing assistants in LTC settings. A study of 164 licensed nurses from 24 LTC facilities in north central Texas found deficiencies in their knowledge of palliative care. The mean score on the Palliative Care Quiz for Nursing was 12.3 of a possible 20 (62%, SD = 2.7). Implications for practice include a critical need for in-service education on end-of-life content for practicing LTC nurses and integration of such content in all curricula for future nurses.     

Development of a palliative care education program in rural long-term care facilities

In North America, people 85 years and older are the fastest growing age cohort and long-term care homes are increasingly becoming the place of end-of-life care. This is especially true in rural communities where services are lacking. Staff in long-term care homes lack education about palliative care, but in rural areas, accessing education and the lack of relevant curricula are barriers. The focus of this paper is to describe an approach to developing and delivering a research-based palliative care education curriculum in rural long-term care homes. The approach included conducting a detailed assessment of staffs' educational needs and preferred educational formats; developing a 15-hour interprofessional curriculum tailored to the identified needs; and delivering the curriculum on site in rural long-term care homes. Staff confidence and participation in delivering palliative care increased. Based on work in northwestern Ontario, Canada, this approach can serve as a model for palliative care education in other rural areas.     

Dying in a rural residential aged care facility: an action research and reflection project to improve end-of-life care to residents with a non-malignant disease

This article describes a qualitative research project that explored issues around end-of-life care provided to residents dying from non-malignant diseases in two, rural Australian, residential aged care facilities. Reflective processes and action research were combined to work in collaboration with 14 aged nurses, associated staff and relatives of dying residents. Reflection featured in the research and included group reflection on practice stories, critical reflection during thematic analysis and reflection on action research cycles. Themes and subthemes emerged, indicating that aspects of end-of-life care needed further improvement. Major thematic concerns were prioritized for action and included the need for better pain management practices which will be discussed. Identifying these clinical issues was an important step in creating, implementing and evaluating actions. Participants reported varying degrees of success in attempting to improve end-of-life care.     

A Measure of Palliative Care in Nursing Homes

ContextEfforts to improve care for nursing home residents stand to be enhanced by measures to assess the degree to which staff provide palliative care. As the incidence of death in nursing homes increases with the aging population, the gap in measurement must be addressed. To that end, we report the development and psychometric testing of a nursing home palliative care survey.ObjectivesThe purpose of this study was to evaluate the psychometric properties of the Palliative Care Survey (PCS) for use in nursing homes.MethodsPsychometric evaluation of the instrument was completed in two phases. Phase 1 focused on individual item analyses and subsequent revision or deletion of items, and Phase 2 evaluated evidence for reliability and validity. Phase 1 included 26 nursing homes and staff (n = 717), and Phase 2 included 85 nursing homes and staff (n = 2779). Data were analyzed using item-total correlations, Cronbach’s alpha, confirmatory factor analysis, and analysis of variance.ResultsSupport was obtained for a 51-item PCS made up of two constructs, Palliative Care Practice and Palliative Care Knowledge.ConclusionThe PCS measures the extent to which the nursing home staff engage in palliative care practices and have knowledge consistent with good end-of-life care. Both practice and knowledge are an essential foundation to providing good end-of-life care to nursing home residents. Efforts to improve care for the dying in nursing homes have been slowed by an absence of measurement tools that capture care processes, a gap that the PCS reported here helps fill.     

Improving end-of-life care education in home care

A training program for home care professionals, HOPE (Home care Outreach for Palliative care Education), was designed to improve the knowledge and skills of those providing care to patients and family caregivers at home. This article presents an overview of the pilot HOPE training program and a case study to illustrate the complex end-of-life (EOL) care needs in nonhospice home care settings. HOPE was designed as five training modules based on a needs assessment survey completed by 134 home care agencies. The training modules were composed of (a) General Overview of End of Life Care; (b) Pain Management; (c) Symptom Management; (d) Communication with Patients and Families; and (e) the Death Event. The program was implemented for clinical staff (N = 52), predominantly nurses, in two home care agencies and evaluated with pre- and postcourse surveys. Pre- and postcourse evaluations demonstrated an increase in the overall rating of EOL care from a mean rating of 5.97 to 7.42 for self-assessment and from 6.59 to 7.94 for agency assessment (on a scale of 0 = not at all effective to 10 = very effective). Future palliative care education should also include evaluation of the impact of such programs on patient care. We concluded that increasing palliative care knowledge of home care professionals is necessary to improve patient care at the EOL.     

Palliative care education for care workers in aged care: A scoping review

BackgroundGlobally, residential aged care is a common place to receive palliative care. Yet 70% of the workforce is made up of unregulated health care workers, many of whom have no formal palliative care education and report a lack of knowledge and ability to provide best practice palliative care.QuestionDoes the provision of palliative care education to unregulated health care workers in residential aged care, improve knowledge, confidence, and ability to provide best practice care to residents with palliative care needs?MethodsA literature search utilising health care databases CINAHL, MEDLINE, and AgeLine was conducted. Citations were screened against the inclusion criteria and the methodology from the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis, assisted in selecting articles that informed the research question.FindingsNine articles met the inclusion criteria. Four areas of interest were derived: (i) Palliative Care knowledge and confidence; (ii) Communication skills; (iii) Roles and responsibilities; (iv) Barriers to implementation and sustainability.DiscussionEvidence suggests the provision of palliative care education to unregulated health care workers may be beneficial in imparting knowledge and confidence, ultimately resulting in an improved ability to provide best practice care. However, barriers within the aged care system may interfere with the implementation and sustainability of newly acquired knowledge. Limitations of the review include the unknown quality of the educational content provided.ConclusionPalliative care education is part of the solution to enhanced outcomes for aged care residents but is not the complete answer. Systemic industry change is required to achieve sustainable outcomes.     

The challenges and opportunities in providing end-of-life care in nursing homes

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.     

Relationships among nursing student palliative care knowledge,experience, self-awareness,and performance: An end-of-life simulation study

BackgroundPalliative care education and experience are needed for student competence in delivering high-quality palliative nursing care. Simulation has been linked to acquired clinical competency among pre-licensure students. A known literature gap is measurement of students' performance during end-of-life simulations.ObjectivesThe aim of this study was to determine relationships among previous palliative care nursing experience, knowledge, self-awareness, and performance in nursing students during an end-of-life simulation.Design/Setting/ParticipantsA quasi-experimental pretest/posttest design was used to assess these variables with a convenience sample of 75 senior nursing students during an end-of-life simulation at a Midwest Jesuit university.MethodsSelf-awareness was measured with the Frommelt Attitudes Toward Care of the Dying, Form B. The Palliative Care Quiz for Nursing measured participants' knowledge. Participants' performance during the simulation was measured using a modified version of the Creighton Competency Evaluation Instrument®. Palliative care nursing self-awareness and knowledge were assessed before and after the simulation. Previous end-of-life care experience was assessed with a single demographic question at pretest only.ResultsThe sample was highly experienced in end-of-life care (93.3% reporting experience pre-simulation). Although pretest self-awareness (M = 124.5; ±1.3) and knowledge (M = 57.1%; ±2.2) were higher in students with two or more types of end-of-life experience (n = 42), there were no significant differences (p > .10) in these outcomes by groups pre- or post-simulation. Self-awareness (M = 130.1; ±1.2), knowledge (M = 80.5%; ±2.6), and performance (M = 94.1%; IQR 87.5 to 100) scores were high for student participants (n = 36) post-simulation, with moderate correlations found between some scores (r_pb < −0.40 or 0.40).ConclusionsFindings support self-awareness and knowledge as antecedents of high quality palliative nursing care. Students demonstrated increased post-simulation knowledge, self-awareness, and quality performance of palliative nursing care regardless of previous end-of-life experience. End-of-life simulation is supported as an education method for increasing palliative care nursing competence and assessing student performance of palliative care nursing interventions.     

Politics, palliation, and Canadian progress in end-of-life care

How do health care consumers, private sector organizations, professionals, and government agencies work toward ensuring quality end-of-life care? This challenge is by no means uniquely Canadian; our approach may thus have applications that extend well beyond our national borders. Raising the profile of palliative care in Canada has occurred on many fronts. Local, provincial, and national efforts in end-of-life care have long been underway. The Canadian Palliative Care Association has been particularly active, recently organizing various stakeholder groups to develop a strong national advocacy partnership for quality end-of-life care. Perhaps most distinctive has been the involvement and nationwide visibility of Canada's Senate. Their report, Quality End-of-Life Care: The Right of Every Canadian has seen Canadian palliative care gain unprecedented momentum. The federal government recently took the unprecedented step of creating a new office to represent palliative care within the federal cabinet. In Canada, it would appear that palliative care is an idea whose time has come.     

Factors influencing models of end-of-life care in nursing homes: results of a survey of nursing home administrators

Approximately 20% of deaths in the United States occur in nursing homes. Dying nursing home residents have unique care needs, which historically have been inadequately addressed. The goal of this study was to determine what factors influence nursing home administrators' choice of model for end-of-life care in their facilities. Thirty nursing home administrators in the Denver, Colorado, metropolitan area were interviewed. The interview used open-ended questions about: facilities' end-of-life care programming and factors that influenced which model was used; scalar questions measuring administrators' attitudes about aspects of end-of-life care; and questions that assessed key demographic characteristics of participants. Twenty-nine of the 30 facilities included in this study reported contracting with hospice. Five were also in the process of creating in-house palliative care teams, and an additional five were negotiating with hospice agencies to dedicate beds for use as hospice units. For profit status, larger facility size, and shorter duration of administrator tenure were found to be associated with greater likelihood of considering implementation of a facility-based end-of-life care model. When asked about obstacles to providing quality end-of-life care, the majority of participants (n = 16) cited an educational deficit among physicians, staff, or the public as the most significant, while an additional seven cited staff shortages and turnover. These results suggest at least two potential avenues for change to improve end-of-life care in nursing homes: (1) educational efforts on the topics of end-of-life and palliative care among both practitioners, residents, and their families, and (2) creating incentives to improve staff recruitment and retention.