Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents

ObjectiveTo determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness.DesignPragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices.Setting and ParticipantsPROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively.MethodsOutcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life).ResultsHospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = ?1.7%, 95% CI –3.2%, ?0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms.Conclusions and ImplicationsVideo-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.     

Change in Advance Care Plans of Nursing Home Residents With Dementia and Pneumonia: Secondary Analysis of Randomized Controlled Trial Data

ObjectivesTo explore changes in advance care plans of nursing home residents with dementia following pneumonia, and factors associated with changes. Second, to explore factors associated with the person perceived by elderly care physicians as most influential in advance treatment decision making.DesignSecondary analysis of physician-reported PneuMonitor trial data.Setting and ParticipantsThe PneuMonitor trial took place between January 2012 and May 2015 in 32 nursing homes across the Netherlands; it involved 429 residents with dementia who developed pneumonia.MethodsWe compared advance care plans before and after the first pneumonia episode. Generalized logistic linear mixed models were used to explore associations of advance care plan changes with the person most influential in decision making, with demographics and indicators of disease progression. Exploratory analyses assessed associations with the person most influential in decision making.ResultsFor >90% of the residents, advance care plans had been established before the pneumonia. After pneumonia, treatment goals were revised in 15.9% of residents; 72% of all changes entailed refinements of goals. Significant associations with treatment goal changes were not found. Treatment plans changed in 20.0% of residents. Changes in treatment decisions were more likely for residents who were more severely ill (odds ratio 1.5, 95% CI 1.2-1.9) and those estimated to live <3 months (odds ratio 3.3, 95% CI 1.9-5.8). Physicians reported that a family member was often (47.4%) most influential in decision making. Who is most influential was associated with the resident’s dementia severity.Conclusions and ImplicationsOverall, changes in advance care plans after pneumonia diagnosis were small, suggesting stability of most preferences or limited dynamics in the advance care planning process. Advance care planning involving family is common for nursing home residents with dementia, but advance care planning with persons with dementia themselves is rare and requires more attention.     

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

ObjectiveTo evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.DesignSystematic review and meta-analysis.Setting and ParticipantsNursing homes and nursing home residents.MethodsA literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).ResultsThe initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: ?0.04, 95% CI ?0.14 to ?0.06; I² = 0%).Conclusion and ImplicationsACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.     

Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic

ObjectivesTo explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic.DesignQualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic.Setting and ParticipantsPhysicians in Dutch nursing homes.MethodsRespondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data.ResultsA total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP, and decision making in ACP. COVID-19–specific changes in ACP indicated by respondents included (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making.Conclusions and ImplicationsACP in Dutch nursing homes has changed because of the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision-making process in ACP.     

Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review

ObjectivesThe aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations.DesignA systematic review with a narrative summary.Setting and ParticipantsResidents in nursing homes and other long-term care facilities.MethodsWe searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed.ResultsThe search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial.Conclusions and ImplicationsIrrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.     

Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis

ObjectiveTo systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.DesignSystematic review and meta-analyses.Data SourcesMedline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.Study SelectionRandomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.Data Extraction and SynthesisFifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: ‘advance directives’ and ‘communication.’Main Outcomes and MeasuresPrimary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.ResultsInterventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.ConclusionsACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.     

Impact of Prior Home Care on Length of Stay in Residential Care for Australians With Dementia

ObjectivesTo assess the impact of home care on length-of-stay within residential care.DesignA retrospective observational data-linkage study.Setting and ParticipantsIn total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014.MethodsSurvey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care.ResultsPeople with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups.ConclusionsHigh-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care.ImplicationsBetter transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.     

Hospice Family Members' Perceptions of and Experiences With End-of-Life Care in the Nursing Home

Objective

Even though more than 25% of Americans die in nursing homes, end-of-life care has consistently been found to be less than adequate in this setting. Even for those residents on hospice, end-of-life care has been found to be problematic. This study had 2 research questions; (1) How do family members of hospice nursing home residents differ in their anxiety, depression, quality of life, social networks, perceptions of pain medication, and health compared with family members of community dwelling hospice patients? (2) What are family members’ perceptions of and experiences with end-of-life care in the nursing home setting?

Methods

This study is a secondary mixed methods analysis of interviews with family members of hospice nursing home residents and a comparative statistical analysis of standard outcome measures between family members of hospice patients in the nursing home and family members of hospice patients residing in the community.

Results

Outcome measures for family members of nursing home residents were compared (n = 176) with family members of community-dwelling hospice patients (n = 267). The family members of nursing home residents reported higher quality of life; however, levels of anxiety, depression, perceptions of pain medicine, and health were similar for hospice family members in the nursing home and in the community. Lending an understanding to the stress for hospice family members of nursing home residents, concerns were found with collaboration between the nursing home and the hospice, nursing home care that did not meet family expectations, communication problems, and resident care concerns including pain management. Some family members reported positive end-of-life care experiences in the nursing home setting.

Conclusion

These interviews identify a multitude of barriers to quality end-of-life care in the nursing home setting, and demonstrate that support for family members is an essential part of quality end-of-life care for residents. This study suggests that nursing homes should embrace the opportunity to demonstrate the value of family participation in the care-planning process.     

A Longitudinal,Randomized, Controlled Trial of Advance Care Planning for Teens With Cancer: Anxiety,Depression, Quality of Life,Advance Directives,Spirituality

PurposeTo test the feasibility, acceptability and safety of a pediatric advance care planning intervention, Family-Centered Advance Care Planning for Teens With Cancer (FACE-TC).MethodsAdolescent (age 14–20years)/family dyads (N = 30) with a cancer diagnosis participated in a two-armed, randomized, controlled trial. Exclusion criteria included severe depression and impaired mental status. Acceptability was measured by the Satisfaction Questionnaire. General Estimating Equations models assessed the impact of FACE-TC on 3-month post-intervention outcomes as measured by the Pediatric Quality of Life Inventory 4.0 Generic Core Scale, the Pediatric Quality of Life Inventory 4.0 Cancer-Specific Module, the Beck Depression and Anxiety Inventories, the Spiritual Well-Being Scale of the Functional Assessment of Chronic Illness Therapy–IV, and advance directive completion.ResultsAcceptability was demonstrated with enrollment of 72% of eligible families, 100% attendance at all three sessions, 93% retention at 3-month post-intervention, and 100% data completion. Intervention families rated FACE-TC worthwhile (100%), whereas adolescents' ratings increased over time (65%–82%). Adolescents' anxiety decreased significantly from baseline to 3 months post-intervention in both groups (β = −5.6; p = .0212). Low depressive symptom scores and high quality of life scores were maintained by adolescents in both groups. Advance directives were located easily in medical records (100% of FACE-TC adolescents vs. no controls). Oncologists received electronic copies. Total Spirituality scores (β = 8.1; p = .0296) were significantly higher among FACE-TC adolescents versus controls. The FACE-TC adolescents endorsed the best time to bring up end-of-life decisions: 19% before being sick, 19% at diagnosis, none when first ill or hospitalized, 25% when dying, and 38% for all of the above.ConclusionsFamily-Centered Advance Care Planning for Teens With Cancer demonstrated feasibility and acceptability. Courageous adolescents willingly participated in highly structured, in-depth pediatric advance care planning conversations safely.     

Purchasing High-Quality Community Nursing Home Care: A Will to Work With VHA Diminished by Contracting Burdens

ObjectivesThe Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA's purchasing policies impede or facilitate contracting with nursing homes.DesignSemistructured interviews of key stakeholders in the VHA's community nursing home contracting process.Setting and ParticipantsWe interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area.MethodsQualitative content analysis of interviews.ResultsFive themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA's reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4) complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA's ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts.Conclusions and ImplicationsNursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.     

Advance Directive and End-of-Life Care Preferences Among Nursing Home Residents in Wuhan,China: A Cross-Sectional Study

Objectives

To describe Chinese nursing home residents' knowledge of advance directive (AD) and end-of-life care preferences and to explore the predictors of their preference for AD.

Design

Population-based cross-sectional survey.

Settings

Nursing homes (n = 31) in Wuhan, Mainland Southern China.

Participants

Cognitively intact nursing home residents (n = 467) older than 60 years.

Measures

Face-to-face questionnaire interviews were used to collect information on demographics, chronic diseases, life-sustaining treatment, AD, and other end-of-life care preferences.

Results

Most (95.3%) had never heard of AD, and fewer than one-third (31.5%) preferred to make an AD. More than half (52.5%) would receive life-sustaining treatment if they sustained a life-threatening condition. Fewer than one-half (43.3%) chose doctors as the surrogate decision maker about life-sustaining treatment, whereas most (78.8%) nominated their eldest son or daughter as their proxy. More than half (58.2%) wanted to live and die in their present nursing homes. The significant independent predictors of AD preference included having heard of AD before (odds ratio [OR] 9.323), having definite answers of receiving (OR 3.433) or rejecting (OR 2.530) life-sustaining treatment, and higher Cumulative Illness Rating Scale score (OR 1.098).

Conclusions

Most nursing home residents did not know about AD, and nearly one-third showed positive attitudes toward it. AD should be promoted in mainland China. Education of residents, the proxy decision maker, and nursing home staff on AD is very important. Necessary policy support, legislation, or practice guidelines about AD should be made with flexibility to respect nursing home residents' rights in mainland China.     

One-Year Medical Utilization and Mortality in Home Health and Nursing Home Care Recipients from Northern Taiwan

ObjectivesHome health care (HHC) and nursing home care (NHC) are mainstays of long-term service in the aged population. Therefore, we aimed to investigate the factors associated with 1-year medical utilization and mortality in HHC and NHC recipients in Northern Taiwan.DesignThis study employed a prospective cohort design.Setting and ParticipantsWe enrolled 815 HHC and NHC participants who started receiving medical care services from the National Taiwan University Hospital, Beihu Branch between January 2015 and December 2017.MethodsMultivariate Poisson regression modeling was used to quantify the relationship between care model (HHC vs NHC) and medical utilization. Cox proportional-hazards modeling was used to estimate hazard ratios and factors associated with mortality.ResultsCompared with NHC recipients, HHC recipients had higher 1-year utilization of emergency department services [incidence rate ratio (IRR) 2.04, 95% CI 1.16-3.59] and hospital admissions (IRR 1.49, 95% CI 1.14-1.93), as well as longer total hospital length of stay (LOS) (IRR 1.61, 95% CI 1.52-1.71) and LOS per hospital admission (IRR 1.31, 95% CI 1.22-1.41). Living at home or in a nursing home did not affect the 1-year mortality.Conclusions and ImplicationsCompared with NHC recipients, HHC recipients had a higher number of emergency department services and hospital admissions, as well as longer hospital LOS. Policies should be developed to reduce emergency department and hospitalization utilization in HHC recipients.     

New Toolkit to Measure Quality of Person-Centered Care: Development and Pilot Evaluation With Nursing Home Communities

BackgroundIncreasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America's Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience.ResultsNH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement.ConclusionsThe no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.     

Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families

ObjectivesTo understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning (ACP) conversations.DesignQualitative study conducted with purposive sampling and semistructured interviews using ATLAS.ti software to assist with template analysis.Settings and ParticipantsParticipants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people.MeasuresInterview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.ResultsCapability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in ACP conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stay in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee’s goal of providing personalized, patient-centered care. Implicit assumptions about patients’ and families’ preferences reduced staff’s motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in prehospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.Conclusions and ImplicationsEven hospice staff can be uncomfortable discussing death and dying. Yet staff were able to identify what worked well. Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.