Narrative accounts of volunteers in palliative care settings

The long and evolving tradition of palliative care has always had a strong volunteer dimension. The difficult nature of palliative care invites questions around why volunteers choose this particular line of contribution. To expand our knowledge of the elements that create meaning and capture the essence of volunteer experience, we asked volunteers to share the rewards and the challenges of their work and its personal meaning. Significant themes emerged around what volunteers considered the most valuable aspects of their experience. Volunteers identified freedom of choice and the ability to use their natural gifts as an important condition for satisfaction. In addition, they perceived emotional resilience and personal hardiness as important dimensions of their suitability for working in palliative care. Finally, volunteers felt that their approach must be one of a balanced perspective, with an understanding of life and death as part of the human condition.     

Case management in long-term care settings

The health care system is a changing environment strongly influenced by the rapid growth of managed care. This change is seen in all aspects of U.S. health care, including extended care settings. Many extended care facilities (ECFs) are forced to review how they deliver care. These facilities are receiving more acutely ill residents as a result of managed care requirements that acute care settings discharge patients much earlier than in the past. These facilities essentially are replacing the hospitals of the 1970s and '80s.     

Strengthening chaplain-physician relationships in long-term care settings

Older, disabled adults are often cared for in long-term settings. Chaplains possess an important role with these older adults and in these settings. This article describes several ways in which chaplains can strengthen relationships with physicians through improved communication.     

Preventing infections in non-hospital settings: long-term care

Infection concerns in long-term care facilities include endemic infections, outbreaks, and colonization and infection with antimicrobial-drug resistant microorganisms. Infection control programs are now used in most long-term care facilities, but their impact on infections has not been rigorously evaluated. Preventive strategies need to address the changing complexity of care in these facilities, e.g., the increased use of invasive devices. The anticipated increase in the elderly population in the next several decades makes prevention of infection in long-term care facilities a priority.     

The RAI-PC: an assessment instrument for palliative care in all settings

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.     

Quality improvement in long-term care

Creating a culture or environment in which total quality can take root is a challenging undertaking for most healthcare organizations. It requires staff at all levels to acquire new skills and problem-solving techniques and apply them in their daily work processes. Change is rarely easy, and it can become all the more difficult in facilities where budgets are strained, staff turnover is high, patients require special attention, and computer-assisted data collection and analysis is still in its infancy. Such is the situation in many long-term care facilities. Some forward-thinking state organizations, long-term care facilities, and national associations are developing strategies to address these issues. Admittedly, these efforts are still in their infancy, but early reports indicate that TQM has the potential to produce results in this field as it has in other healthcare settings.     

Quality of care assessment in long-term care facilities

Quality of care assessment is in a rather rudimentary state of development in most long-term health care settings. Some of the mandates and initiatives in this area of evaluation are described and discussed. A few caveats are presented and suggestions made as to appropriate approaches to quality assessment in chronic care facilities, which are different in many respects from the more traditional approaches used in acute care hospitals. Of particular importance, and at the same time of greatest difficulty, is the assessment of quality of life in institutions where many patients spend the remainder of their lives.     

Orlistat in the long-term treatment of obesity in primary care settings

OBJECTIVE: To evaluate the long-term efficacy and tolerability within primary care settings of orlistat, a gastrointestinal lipase inhibitor, for the treatment of obesity. DESIGN: Randomized, double-blind, placebo-controlled, multicenter study. PARTICIPANTS: A group of 796 obese patients (body mass index, 30-44 kg/m2), treated with placebo 3 times a day (TID), 60 mg of orlistat TID, or 120 mg of orlistat TID, in conjunction with a reduced-energy diet for the first year and a weight-maintenance diet during the second year. SETTING: Seventeen primary care centers in the United States. MAIN OUTCOME MEASURES: Changes in body weight and obesity-related disease risk factors. RESULTS: Patients treated with orlistat lost significantly more weight (7.08 +/- 0.54 and 7.94 +/- 0.57 kg for the 60-mg and 120-mg orlistat groups, respectively) than those treated with placebo (4.14 +/- 0.56 kg) in year 1 (P<.001) and sustained more of this weight loss during year 2 (P<.001). More patients treated with orlistat lost 5% or more of their initial weight in year 1 (48.8% and 50.5% of patients in the 60-mg and 120-mg groups, respectively) compared with placebo (30.7%; P<.001), and approximately 34% of patients in the orlistat groups sustained weight loss of 5% or greater over 2 years compared with 24% in the placebo group (P<.001). Orlistat produced greater improvements than placebo in serum lipid levels and blood pressure and was well tolerated, although treatment resulted in a higher incidence of gastrointestinal events. CONCLUSIONS: This long-term study indicates that orlistat is an effective adjunct to dietary intervention in the treatment of obesity in primary care settings.     

Persistent family concerns in long-term care settings: meaning and management

PURPOSE: The aim of this study was to understand institutional and family caregiver characteristics that contribute to the failure to resolve families' persistent complaints about nursing home care of their relatives. DESIGN AND METHODS: Key informant interviews with 9 family members who had persistent concerns about the care of their relatives were conducted. Two focus groups with 5 nurse managers provided staff perceptions of families whose persistent concerns remained unresolved. Content analysis of both individual interviews and focus groups resulted in the extraction of salient themes. RESULTS: Factors associated with persistent discord between families and staff included caregivers' perceptions of staff as incompetent, interfamilial conflicts, and unresolved psychosocial issues. Institutional factors contributing to persistent negative perceptions of care included staff's vulnerability in the face of challenges to their professional competence and stress due to disproportionate amounts of time spent educating and supporting health care aids to cope with distraught families. IMPLICATIONS: The failure to settle, in a mutually satisfactory manner, the complaints of this subgroup of families is discussed in the context of unresolved family issues that interact with institutional failure to respond in a manner that conveys understanding of caregiver stress that is invariably exacerbated when a family member is placed in a long-term care facility.     

Quality variables for documentation in long-term care

Documentation in long-term care clinical records continues to pose many challenges as the industry adjusts to a period of significant change. This article will look at some of the forces impacting documentation resulting from the first major federal rewrite in 15 years for long-term care facilities participating in Medicare and Medicaid. A short synopsis of the federal regulatory environment that reshaped the core content of the long-term care clinical record will be presented, as well as a discussion of related medicolegal issues, information technology issues, and similar topics affecting long-term care will have a better understanding of the multifaceted forces impacting documentation in the clinical record and thus recognize the importance of documentation as a key quality improvement opportunity for long-term care facilities.