Use of intensive care at the end of life in the United States: an epidemiologic study

OBJECTIVE: Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index. DESIGN: Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents. SETTING: All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington. PATIENTS: All inpatients in nonfederal hospitals in the six states in 1999. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations. CONCLUSIONS: One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.     

Teaching cultural considerations at the end of life: end of life nursing education consortium program recommendations

BACKGROUND: The End of Life Nursing Education Consortium (ELNEC) is an end of life care nursing education program that addresses the many dimensions of culture, including ethnic identity, gender, age, differing abilities, sexual orientation, and religion and spirituality. This article focuses on one of the program's modules entitled "Cultural Considerations in End of Life Care." METHOD: The ELNEC "Cultural Considerations in End of Life Care" module, which identifies important cultural considerations as well as strategies and responses to teach cultural competence and sensitivity in undergraduate nursing curriculum, is described. FINDINGS: A total of 564 nursing faculty members and 707 continuing education faculty members have undergone ELNEC training. Essential module components including teaching strategies and resources are presented. CONCLUSION: Comprehensive education for nurses regarding cultural considerations in end of life care results in improved care for dying patients who ultimately have a peaceful, respectful death with sensitivity to their cultural expectations and needs.     

Drug modification by nurses in Norwegian nursing homes: A cross-sectional study

Crushing and dividing pills among older patients in nursing homes appears to be a common yet not harmless practice. Because few updates exist regarding the role of nurses and their dispensing of drugs in nursing homes, this study sought to describe the occurrence, methods, and causes of nurses’ drug modification and to examine possible factors associated with drug modification in this context. A cross-sectional study of 273 dispensing episodes of solid oral drugs made by nurses, were observed during day and evening shifts. Modifications were made in 20.5% of the dispensing episodes, including 80.4% where alterations were made by crushing and 19.6% where alterations were made dividing. The most commonly reported reasons for modification were ‘swallowing difficulties’ (53.6%) and ‘lack of understanding by the patient’ (19.6%). The logistic regression analysis showed a significant association between the occurrence of drug modification and both cognitive impairment and administration method.     

Urinary incontinence nursing considerations at the end of life

Urinary incontinence occurs at the end of life either as a consequence of treatment(s) for a urologic health condition or as the result of disease progression. End-of-life urinary incontinence conditions include bladder abnormalities (urge, emptying, hesitancy), infection, and/or the need for diversional methods. Alterations in skin integrity may be the result of previous treatment(s) to the urinary system and lower abdomen, or from urinary incontinence. Treated urinary incontinence at the end of life provides dignity and will maintain quality of life. This article describes the urinary care needs and options for individuals receiving end-of-life care.     

Palliative care nursing: Ensuring competent care at the end of life

Major advances in enabling function and symptom management have occurred in the past decade. Older adults who would have been bed-bound at the end of life now can be offered interventions to help them live well until they die. People who once would have suffered from pain can expect to be kept comfortable with aggressive symptom management. Palliative care nursing is the art and science of quality end-of-life care. Appropriate interventions for competent palliative care often are not initiated for dying older adults and their families. Nursing professionals are beginning to assume leadership roles to ensure that comprehensive, holistic end-of-life care is available to all patients and families experiencing life-threatening progressive illnesses.     

Improving the quality of life in nursing homes

Physicians can help improve the quality of life for persons residing in long-term care facilities. Physician visits offer opportunities to share knowledge and skills with the staff, to influence nursing home policies and procedures, and to serve as advocates for residents and their families. The physician can ensure good medical care and can encourage practices that enable residents to use their remaining capacities and have maximum autonomy over their own lives.     

Improving the quality of nursing students' clinical placements in nursing homes: An evaluation study

The aim of this study was to explore students' experiences during their clinical placements in five nursing homes after implementing measures to improve the learning environment.It is vital to stimulate more future nurses to consider a career within geriatric wards and nursing homes. One way to achieve this, is to enhance nursing students' learning experiences during clinical placements in these settings.Measures to improve the learning environment were implemented as a result of a joint effort between a university college and five nursing homes. An explorative design was developed to collect empirical data concerning the students' experiences expressed through questionnaires and logs.The results generally conveyed more positive than negative experiences. Students expressed most satisfaction with peer collaboration, the placement's contribution to awareness of future nursing role and described the learning arena as exciting and interesting. They expressed less satisfaction with supervision from preceptor and how the practice site was prepared for and organized students' placements.Clinical placement arenas and educational institutions should collaborate closely to explore and develop models of supervision appropriate for the nursing home context, to build on existing potentials and resolve the issues that represent barriers for creating interesting and effective learning environments.     

Quality of life at the end of life for nursing home residents: perceptions of hospice and nursing home staff members

This study examined whether the perceptions of nursing staff members about the importance of quality-of-life domains and their perceived ability to influence those domains for residents at the end of life were affected by their institutional affiliation, level of training, or residents' cognitive status. Respondents were 146 Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) from nursing homes and hospices. Magnitude estimation scales were used to rate the importance of and perceived ability to influence 11 quality-of-life domains for both cognitively intact and cognitively impaired residents. Overall, respondents' scores indicated a high level of importance of all quality-of-life domains and similarly positive perceptions that they could influence quality-of-life domains for hypothetical nursing home residents. Analysis of variance revealed that respondents reported lower average importance and ability to influence ratings when considering residents with cognitive impairment. Respondents affiliated with hospice agencies also reported lower average importance and ability to influence ratings on some domains, although the high ratings overall limit the clinical significance of these differences. Importance ratings were not affected by the level of education, but CNAs reported higher perceived ability to influence ratings on four domains than did RNs. Future studies should explore whether the domains measured adequately capture the end-of-life experience in nursing homes.     

An interrater reliability study of the Braden scale in two nursing homes

Background

Adequate risk assessment is essential in pressure ulcer prevention. Assessment scales were designed to support practitioners in identifying persons at pressure ulcer risk. The Braden scale is one of the most extensively studied risk assessment instruments, although the majority of studies focused on validity rather than reliability.

Objectives

The first aim was to measure the interrater reliability of the Braden scale and its individual items. The second aim was to study different statistical approaches regarding interrater reliability estimation.

Design and methods

An interrater reliability study was conducted in two German nursing homes. Residents (n = 152) from 8 units were assessed twice. The raters were trained nurses with a work experience ranging from 0.5 to 30 years. Data were analysed using an overall percentage of agreement, weighted and unweighted kappa and the intraclass correlation coefficient.

Results

Differences between nurses rating the overall Braden score ranged from 0 up to 9 points. Interrater reliability expressed by the intraclass correlation coefficient ranged from 0.73 (95% CI 0.26-0.91) to 0.95 (95% CI 0.87-0.98). Calculated intraclass correlation coefficients for individual items ranged from 0.06 (95% CI −0.31 to 0.48) to 0.97 (95% CI 0.93-0.99) with the lowest values being measured for the items “sensory perception” and “nutrition”. There was no association between work experience and the level of interrater reliability. With two exceptions, simple kappa-values were always lower than weighted kappa-values and intraclass correlation coefficients.

Conclusions

Although the calculated interrater reliability coefficients for the total Braden score were high in some cases, several clinically relevant differences occurred between the nurses. Due to interrater reliability being very low for the items “sensory perception” and “nutrition”, it is doubtful if their assessment contributes to any valid results. The calculation of weighted kappa or intraclass correlation coefficients is the most appropriate interrater reliability estimates.     

Three nursing home residents speak about meaning at the end of life

This article provides a deeper understanding of how meaning can be created in everyday life at a nursing home. It is based on a primary study concerning dignity involving 12 older people living in two nursing homes in Sweden. A secondary analysis was carried out on data obtained from three of the primary participants interviewed over a period of time (18-24 months), with a total of 12 interviews carried out using an inductive hermeneutic approach. The study reveals that sources of meaning were created by having a sense of: physical capability, cognitive capability, being needed, and belonging. Meaning was created through inner dialogue, communication and relationships with others. A second finding is that the experience of meaning can sometimes be hard to realize.     

Feeling at home in nursing homes

AIM: The purpose of this study was to examine determinants of feeling at home and in particular the privacy in nursing homes in The Netherlands. The first question was to what extent nursing homes differed in the degree residents feel at home and experience privacy. The second question was whether feeling at home is related to privacy in the nursing homes. BACKGROUND: Feeling at home is of particular importance to residents of nursing homes because the average length of stay in The Netherlands is about 16 months. A growing number of people are of the opinion that the privacy of the residents has to be improved. Privacy in nursing homes, therefore, has been high on the political agenda over the last few years. Four aspects of privacy were distinguished: privacy related to the characteristics of the building, privacy as a consequence of the attitude of nurses towards residents, privacy in terms of choice and control over time schedules and activities, and privacy related to the amount of disturbance caused by other residents. DESIGN: The data were collected from individual interviews with 686 residents and family-members in 36 nursing homes in The Netherlands. RESULTS: Following quantitative data analysis, it was found that nursing homes differed in the proportion of residents feeling at home as well as in three aspects of privacy. Differences in feeling at home were found to be related to privacy, especially to the perceived attitudes of nurses and perceived disturbance caused by other residents. A weak relationship was found between residents and their perceived privacy of the building. CONCLUSIONS: A significant amount of variation in privacy was found at the nursing home level. This implies that feeling at home is not only individually determined but can be influenced by the nursing home's management policy.     

A support group for nursing assistants: caring for nursing home residents at the end of life.

Certified nursing assistants (CNAS) provide the hands-on care to residents in nursing homes, often developing close relationships with those in their care. The current study used a support program model to explore CNAS' feelings, experiences, and needs when caring for the dying. Special attention was given to the experience of caring for residents who opted not to continue life-sustaining treatment. Second, the efficacy of this type of support program for CNAS was examined. Care of the dying elicited complex reactions: most CNAS reported that caring for dying residents can be a very rewarding experience. At the same time, most thought that caring for a dying person is always emotionally draining. Moreover, CNAS said they felt sad and felt stressed at least some of the time when caring for the dying. CNAS participated openly in the discussion and expressed positive feelings about participating in this type of support program.