Advance care planning and end-of-life care for hospitalized nursing home residents

OBJECTIVES: To describe advance care planning (ACP) and end-of-life care for nursing home residents who are hospitalized in the last 6 weeks of life. DESIGN: Constant comparative analysis of deceased nursing home resident cases.SETTING: A not-for-profit Jewish nursing home. PARTICIPANTS: Forty-three deceased residents hospitalized within the last 6 weeks of life at a tertiary medical center. MEASUREMENTS: Trained nurse reviewers abstracted data from nursing home records and gerontological advanced practice nurse field notes. Clinical and outcome data from the original study were used to describe the sample. Data were analyzed using the constant comparative method and validated in interviews with a gerontological advanced practice nurse and social worker. RESULTS: The analysis revealed distinct characteristics and identifiable transition points in ACP and end-of-life care with frail nursing home residents. ACP was addressed by social workers as part of the nursing home admission process, focused primarily on cardiopulmonary resuscitation preference, and reviewed only after the crisis of acute illness and hospitalization. Advance directive forms specifying preferences or limitations for life-sustaining treatment contained inconsistent language and vague conditions for implementation. ACP review generally resulted in gradual limitation of life-sustaining treatment. Transition points included nursing home admission, acute illness or hospitalization, and decline toward death. Relatively few nursing home residents received hospice services, with most hospice referrals and palliative care treatment delayed until the week before death. Most residents in this sample died without family present and with little documented evidence of pain or symptom management. CONCLUSION: Limiting discussion of advance care plans to cardiopulmonary resuscitation falsely dichotomized and oversimplified the choices about medical treatment and care at end-of-life, especially palliative care alternatives, for these older nursing home residents. Formal hospice services were underutilized, and palliative care efforts by nursing home staff were often inconsistent with accepted standards. These results reinforce the need for research and program initiatives in long-term care to improve and facilitate individualized ACP and palliative care at end of life.     

Errors and omissions in diagnostic records on admission of patients to a nursing home.

The primary and secondary diagnoses for 100 geriatric patients consecutively admitted to a nursing home were reviewed for accuracy and omissions. Primary diagnoses were identified as the direct basis for nursing home admission. Other physical, biochemical or behavioral disorders requiring continued therapeutic care were identified as secondary diagnoses. A comparison was made of the diagnosis offered by the referring physician and the diagnosis as determined by the medical staff of the nursing home immediately after admission. In 64 percent, the secondary diagnoses were either lacking or inaccurate. The extraordinarily inadequate medical performance with respect to identifying the primary clinical and therapeutic problems of the chronically ill aged was remarkably consistent, regardless of the source of the patient's referral, whether from a general or psychiatric hospital, a private home, or another nursing home. The results of this study revealed a significant degree of unpreparedness and malaise in some members of the medical profession concerning the care of the chronically ill aged, particularly when such patients demonstrate behavioral disorders superimposed upon physical disease. Failure to identify the patient's needs through diagnosis must result in poor, inadequate or inappropriate treatment programs.     

Level of care and complications among geriatric patients discharged from the medical service of a teaching hospital

To assess the effects of hospitalization on the subsequent placement and supportive care of elderly patients, the medical records of 233 consecutive patients aged 75 years or older, admitted to the medical service of a university hospital, were reviewed. The level of care on admission and at discharge, hospital-associated complications, and demographic data were abstracted for each patient. At discharge, 1 per cent returned to a nursing home, 6 per cent were newly placed in a nursing home, 65 per cent returned to the same level of care as on admission, 10 per cent returned home with an increased level of care, and 18 per cent died or were discharged to another acute care facility. Complications occurred in 30 per cent of patients but did not correlate with age, increased level of care at discharge, or increased rate of nursing home placement. Few elderly patients were discharged to nursing homes, and most returned home without arrangements for increased care.     

Relatives’ experience of nursing home admissions: preliminary study

Objective: As the first of a three‐phase study examining nursing home admissions, the current paper reports on relatives’ subjective experience of admitting an older family member to a nursing home. Methods: Fifty‐eight relatives from northern New South Wales (NSW) and South Australia who had admitted a family member into an aged care home were interviewed. Results: A broad range of positive and negative experiences were recounted by relatives who had been involved in a nursing home admission of a family member. Although there was a diversity of responses, a number of common themes were identified in the interviews. These included the inability to cope with supporting an older person, difficulties in finding a nursing home, disheartening admission processes, and a broad range of emotional responses including guilt, distress and relief. Conclusions: Admission of a family member to a nursing home can be a difficult and emotional time for relatives. The complex and sensitive nature of this process highlights the importance of recognition and support for relatives from health care professionals in aged care.     

上海市部分养老机构老年人体检及结核病核心知识知晓情况现况调查

目的 掌握上海市养老机构入住的老年人接受体检和社会家庭关怀情况及结核病核心信息知晓程度。方法 2017年9—12月,从上海市3个城区和4个郊区中分别按养老机构名单排列顺序依次选取3家养老机构,对养老机构入住的老年人开展调查;21家养老机构共登记在册老年人3717名,对其中符合纳入条件(年龄≥60岁、未出现意识模糊或相关重大疾病、可进行正常沟通、愿意接受调查)的438名老年人开展问卷调查;对其人口学特征、基本健康状况等进行描述性分析,并对城区和郊区养老机构老年人接受体检、家庭社会关怀情况,以及对结核病核心信息的知晓情况进行比较。结果 21家养老机构共438名老年人接受了调查,男性占36.8%(161/438),80岁及以上者占75.8%(332/438),本市户籍者占92.7%(406/438),学历为中学及以下者占90.9%(398/438),入住时长为1~5年者占56.8%(249/438),有慢性疾病史者占88.6%(388/438),有2种及以上慢性疾病的老年人占50.9%(223/438)。82.9%(363/438)的老年人入住前曾接受过胸部X线摄影检查,28.3%(124/438)的老年人入住后未进行胸部X线摄影检查;城区养老机构的老年人入住前(93.2%,179/192)及入住后(88.0%,169/192)接受X线摄影检查率均高于郊区养老机构老年人(74.8%,184/246;58.9%,145/246),差异均有统计学意义(χ ²值分别为25.82和44.92,P值均<0.001)。35.4%(155/438)的老年人被探望的频次<1次/周;城区养老机构老年人每周得到家属探望的比例(78.6%,151/192)高于郊区(53.7%,132/246),差异有统计学意义(χ ²=29.45,P<0.001)。70.3%(308/438)的老年人一年内没有离开过养老机构。接受调查的老年人对肺结核传染性及传播途径知识的知晓率分别为86.1%(309/359)和72.5%(224/309),仅29.0%(104/359)的老年人在咳嗽超过2周时会怀疑患肺结核。结论 养老机构入住老年人接受体检及社会关怀情况仍有待加强,将结核病筛查与老年人定期健康体检或慢性病随访有机结合,同时加强结核病知识的宣传教育,将有助于肺结核患者的早期发现。     

Healthcare utilization of elderly persons hospitalized after a noninjurious fall in a Swiss academic medical center

OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03-3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs.     

The influence of clinical problems, age and social support on outcomes for elderly persons referred to regional aged care assessment teams

Abstract Background: Aged Care Assessment Teams (ACATs) have been established throughout Australia during the past seven years. Early studies of their effect have concentrated on their impact on the rate of institutionalisation of disabled elderly, the clinical characteristics of referred cases and the relationship between disability and recommended care plan. Aims: The aim of this study was to explore the relationship between age, clinical features and social characteristics of AC AT subjects with outcomes at 12 months after assessment. Methods: The examination of an arbitrary sample of persons referred to ACATs over a year by one generalist geriatrician with follow-up of all cases by the three ACATs associated with the study was carried out. All analyses were performed on raw data presented as categorical variables in the form of contingency tables. Results: The sample included 324 subjects who suffered from 2030 clinical problems with a mean of 6.5 per person aged 75 or over and 5.5 for those under 75. Cardiovascular and neurological disease were the commonest source of problems. Study of accommodation outcome at 12 months, for those subjects who survived this period revealed that, in the older group, over 60% of subjects with neurological disease were resident in nursing homes while the majority of all other groups remained in the community, as did two-thirds of those aged under 75. Admission to a nursing home was independent of social support for older subjects with neurological disease, but it played a significant role in those with cardiopulmonary or musculoskeletal disease. Conclusions: The study demonstrates that for one-year survivors there is an increased likelihood of admission to a nursing home of people aged 75 or over with neurological disease, while those under 75 were more likely to remain at home. The association was independent of whether spouse, family or friends were living with the subject. (Aust NZ J Med 1994; 24: 378–385.)     

The domiciliary assessment visit in hospital geriatric practice: pressures and dicisions on needs for admission

In a sample of 230 cases, requests for admission to a hospital geriatric unit were assessed, in the patients' homes, by a physician and his associate. The physician recorded his opinion of the strength of 14 factors influencing his decisions and also of total admission pressure. Each case was affected by an average of five different factors. Medical factors were most commonly noted: chronic physical illness in 94% of patients, chronic mental illness in 70%; but acute physical illness in only 34%. Difficult nursing was recorded in 76% of cases: other social factors were noted less frequently and related mainly to problems of support. The analysis suggested the importance of the chronic physical illness, difficult nursing, an short-term advantage factors in their contribution to a decision on the need for admission. The chronic mental factor appeared to affect the decision independently of the other factors. It was considered that half the patients were very strongly in need of admission; but a third gave no, or weak, admission pressure, were too ill to be moved, or refused to leave home.     

The effect of a social work intervention to enhance advance care planning documentation in the nursing home

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.     

Predictors of nursing home admission for older adults hospitalized with heart failure

The objective of this retrospective chart review study was to determine the prevalence and predictors of nursing home admission of older hospitalized heart failure patients. Subjects were Medicare beneficiaries discharged with a principal diagnosis of heart failure in 1994 in the state of Alabama, United States. The outcome variable was admission to a nursing home after hospital discharge. Using multivariable logistic regression analyses we determined patient and care variables independently associated with admission to a nursing home. Patients (n = 985) had a mean (+/- S.D.) age of 79 (+/- 7.5) years, 61% were female and 18% African-American. Eighty-three (8%) patients were admitted to a nursing home. Over 80% of those admitted to a nursing home had prior nursing home residence. After adjustment for various demographic, clinical and care variables, age (adjusted odds ratio [OR] = 1.14; 95% confidence interval [95%CI] = 1.06-1.23), pre-admission residence in a nursing home (adjusted OR = 1422; 95%CI = 341-5923), and length of hospital stay (adjusted OR = 1.11; 95%CI = 1.02-1.20) were independently associated with admission to a nursing home. Among patients with no prior nursing home residency (n = 908), 15 (2%) patients were newly admitted to a nursing home upon discharge. In addition to age and length of stay, diabetes (adjusted OR = 6.46; 95%CI = 1.58-26.41) was independently associated with new admission to a nursing home. In conclusion, nursing home admission rate for this cohort of older hospitalized heart failure patients was low. Age, length of hospital stay, and diabetes were associated with new nursing home admissions. Further studies are needed to identify modifiable risk factors for nursing home admissions and to develop appropriate interventions.     

Lower limb function as predictor of falls and loss of mobility with social repercussions one year after discharge among elderly inpatients

BACKGROUND AND AIMS: Poor mobility of the lower limbs in community-dwelling elderly people is a predictor of functional decline in terms of disability, falls, nursing home admission, and death. However, its predictive value has not been studied in acute care hospital settings. The aims of this observational, prospective study were: 1) to assess the prognostic value of lower limb function; and 2) to compare the predictive value of three performance tests in elderly inpatients. METHODS: We studied 144 patients aged 70 or older (60 men and 84 women, mean age 78.7 +/- 5.6 years), admitted consecutively to a general internal medicine ward. Before discharge, patients underwent multidimensional assessment, including static and dynamic equilibrium and gait, by the Performance-Oriented Mobility Assessment (POMA), Short Physical Performance Battery (SPPB), and Functional Reach (FR). One-year outcomes were falls, loss of mobility with social repercussions (inability to leave home, or need for nursing home care) and death. RESULTS: In univariate analysis, poor results on any of the three tests were associated with an increased risk of falls, loss of mobility with social repercussions, and death. In multivariate analysis, age, two or more falls, and a low POMA score were predictive of future falls, whereas dependency in instrumental activities of daily living and a low SPPB score were predictive of loss of mobility with social repercussions. No multivariate model was superior to univariate ones in predicting death. No associations were found between other medical or geriatric characteristics and outcomes. CONCLUSIONS: Lower limb mobility tests performed in an acute care hospital setting are predictive of future falls, inability to leave home, and/or need for nursing home care.     

Health Outcomes and Geriatric Assessment: Making Literature Reviews Relevant to Current Programs

The rationale for geriatric assessment programs includes a reduction in nursing home admissions, improved health outcomes and improved physical function. However the evidence for these benefits may not be directly transferable to all models of geriatric assessment programs. This study is a review of published studies of most relevance to aged care assessment teams with regard to one important outcome, nursing home admission. However the conclusions are limited in that no studies are directly comparable to the situation in which aged care assessment teams function. In addition, traditional outcome measures may not be appropriate in considering the effectiveness of similar models of geriatric assessment.     

Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status

This article presents results of a prospective multivariate study of hospitalized elderly patients at an acute-care Veterans Administration (VA) hospital to identify factors on hospital admission predictive of several short- and long-term outcomes: in-hospital and 6-month mortality, immediate and delayed nursing home admission, length of hospital stay, and 6-month rehospitalization. All patients aged 70 years and over admitted to acute-care beds on the medical service wards during a 1-year period were included in the study (N = 396). Factors most predictive of 6-month mortality (using logistic regression) were decreased functional status, admitting diagnosis, and decreased mental status. Factors most predictive of nursing home admission were decreased functional status, living location, and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than was principal admitting diagnosis--of relevance to the current emphasis on diagnosis-related groups (DRGs). These data may be helpful in improving discharge planning, in resource allocation, and in targeting patients for different specialized geriatric programs.     

Risk of nursing home admission among older americans: does states' spending on home- and community-based services matter?

OBJECTIVE: States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects. METHODS: We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier. RESULT: State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%. DISCUSSION: Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.     

Causes for in-hospital treatment of nursing home residents

The high rates of hospitalization in nursing home residents are as well known as the hazards of in-hospital treatment especially in this group of frail older people. Moreover, hospital admissions cause considerable costs. The objective of the study was to analyze why nursing home residents are admitted for in-hospital geriatric care, and to form hypotheses of how to prevent these admissions without loss of quality of care. Reason of admission, comorbidity, competence and length of in-hospital stay were assessed in all nursing home residents referred to the Geriatric Centre at the University Hospital of Heidelberg over 12 months. There were 245 admissions of 231 nursing home residents (83.1% female; age 84.2 +/- 7.10 years). Comorbidity was substantial (77% urinary incontinence, 69% dementia, 40% stool incontinence, 22% pressure ulcers), and 56% of residents needed assistance in using the toilet before admission. Mean length of in-hospital stay was 32.6 days (median 29 days). Out of a total amount of 7983 days of in-hospital care, 3627 (45%) were caused by falls and fractures, 2039 (26%) by cardiovascular events (mainly ischemic stroke), 835 (11%) by infections and 495 (6%) by problems concerning nutrition. Most of the leading causes of admission of nursing home residents to in-hospital geriatric care might be affected by improvements in nursing home care. Thus, data suggest that hospitalization rates might be substantially reduced by targeted prevention and therapy as well as by structural measures to improve case management in the nursing homes. Such interventions should be developed and proved in controlled studies.     

Caring too much? Lack of public services to older people reduces attendance at work among their children

The need to provide care for older people can put a strain on their adult children, potentially interfering with their work attendance. We tested the hypothesis that public care for older people (nursing homes or home care services) would moderate the association between having an older parent in need of care and reduced work attendance among the adult children. The analysis used data from a survey of Norwegian employees aged 45–65 (N = 529). Institutional care for older people in need of care (i.e. nursing homes) was associated with improved work attendance among their children—their daughters in particular. Data also indicated a moderating effect: the link between the parents’ reduced health and reduced work attendance among the children was weaker if the parent lived in a nursing home. However, the results were very different for home-based care: data indicated no positive effects on adult children’s work attendance when parents received non-institutionalised care of this kind. Overall, the results suggest that extending public care service to older people can improve their children’s ability to combine work with care for parents. However, this effect seems to require the high level of care commonly provided by nursing homes. Thus, the current trend towards de-institutionalising care in Europe (and Norway in particular) might hamper work attendance among care-giving adult children, women in particular. Home care services to older people probably need to be extended if they are intended as a real alternative to institutional care.     

Factors influencing death at home in terminally ill cancer patients

Aim: The purpose of this study is to investigate factors affecting terminally ill cancer patients dying at home. Material: Ninety‐two terminally ill cancer patients who were receiving home medical care services and died between April 2005 and December 2006 were included in the study. The data included patients' and caregivers' demographic characteristics, disease‐related information, place of death, and status of home care support. To identify the factors predicting the place of death, multivariate logistic regression analyses were performed. Results: Patients of families who had no preference regarding the place of death or a preference for death at home were more likely to die at home (vs preference for hospital death, odds ratio = 5.87, 95% confidence interval = 1.02–36.53; odds ratio = 90.35, 95% confidence interval = 8.15–1001.51, respectively) after adjusting for potential confounders. Meanwhile, if the patient's family preferred that the patient not die at home, the patient's place of death was not at his/her home irrespective of his/her preference. Conclusion: The results suggested the stronger involvement of families' preferences regarding the patients' place of death over patients' own preferences. Therefore, factors affecting families' preferences need to be clarified for the dissemination of death at home for terminally ill cancer patients.     

Wishes of nursing home residents concerning their life situation--results of a qualitative study

OBJECTIVE: This study examined the wishes of nursing home residents concerning their life situation in the nursing home. METHODS: Using a qualitative study design, a representative sample of nursing home residents (n = 1656) of 24 nursing homes in a city situated in the eastern part of Germany were interviewed. RESULTS: The analyses of residents' wishes lead to major domains such as the quality of care, interpersonal contact, architecture and organization of the house, diversification, financial support, as well as themes like health and death and the wish to leave the nursing home. Residents focus on an individualized approach to care. CONCLUSIONS: Nursing home residents' views support the need to improve the psychological and social aspects of the quality of care. Implications of and consequences for the organization of care and concepts of nursing are discussed.     

Do social networks affect the use of residential aged care among older Australians?

Background

Older people's social networks with family and friends can affect residential aged care use. It remains unclear if there are differences in the effects of specific (with children, other relatives, friends and confidants) and total social networks upon use of low-level residential care and nursing homes.

Methods

Data were drawn from the Australian Longitudinal Study of Ageing. Six waves of data from 1477 people aged ≥ 70 collected over nine years of follow-up were used. Multinomial logistic regressions of the effects of specific and total social networks on residential care use were carried out. Propensity scores were used in the analyses to adjust for differences in participant's health, demographic and lifestyle characteristics with respect to social networks.

Results

Higher scores for confidant networks were protective against nursing home use (odds ratio [OR] upper versus lower tertile of confidant networks = 0.50; 95%CI 0.33–0.75). Similarly, a significant effect of upper versus lower total network tertile on nursing home use was observed (OR = 0.62; 95%CI 0.43–0.90). Evidence of an effect of children networks on nursing home use was equivocal. Nursing home use was not predicted by other relatives or friends social networks. Use of lower-level residential care was unrelated to social networks of any type. Social networks of any type did not have a significant effect upon low-level residential care use.

Discussion

Better confidant and total social networks predict nursing home use in a large cohort of older Australians. Policy needs to reflect the importance of these particular relationships in considering where older people want to live in the later years of life.