Interdisciplinary End-of-Life Care in Nursing Homes

ABSTRACT

About 25% of deaths in the United States now occur in nursing homes, and this proportion is increasing. Current end-of-life (EOL) care in these facilities faces substantial challenges, including under-management of pain, dyspnea, and other symptoms, a clash of cultures between palliative care/hospice teams and the nursing facility, and reimbursement policy that discourages the use of hospice. For ethnic minorities, these challenges are more striking. Improvement in EOL care in nursing homes requires integration between the traditional rehabilitative/restorative mission of long-term care and the palliative model of hospice. Education, better utilization of hospice, cooperation in quality improvement, and changes in reimbursement policy will lead to better care for these increasingly frail and elderly patients.     

End-of-Life Care in Patients With Heart Failure

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.     

End-of-Life Care from the Perspective of Primary Care Providers

PURPOSE

To explore the factors influencing primary care providers?? ability to care for their dying patients in Michigan.

METHODS

We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis.

RESULTS

Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients?? needs quickly; and (5) authority to act on behalf of their patients.

CONCLUSIONS

In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority.     

Management of COPD in End-of-Life Care by Spanish Pulmonologists

ABSTRACT

Chronic obstructive pulmonary disease is progressive and in its advanced stage is associated with major disability. Previous studies suggest that patients with this disease receive little palliative care, even in very advanced stages. Given this, our objectives were to describe the clinical practice of Spanish pulmonologists in the care of patients with end-stage chronic obstructive pulmonary disease, to identify potential barriers to implementing palliative care in these patients and to correlate these responses with doctor's years of experience. A link to an online survey was sent to pulmonologists on (a) symptom management, (b) structure of their department and collaboration with other services, (c) specialized medical training in palliative care, (d) communication with patients and their families, and (e) limiting barriers identified in the management of these patients. A total of 387 responses were received. The majority used opioids to treat dyspnea (52.9%) or pain (54.2%) and many treated anxiety/depression (41%). Around half of the respondents had no established routines in their departments to offer palliative care to patients with chronic obstructive pulmonary disease. There was little communication with end-of-life patients and their families on disease course, mainly associated with a lack of medical training (83% of cases) and changes in patient wishes regarding care through the disease course (81%). In our setting, communication with end-of-life patients with chronic obstructive pulmonary disease is poor. The key challenges identified are insufficient medical training and changing desires of patients. No substantial differences in attitude were found as a function of experience.     

Integrating Spirituality and Culture with End-of-Life Care in Medical Education

ABSTRACT

To provide high-quality care that is responsive to spiritual concerns within a multicultural context, student physicians and other health care professionals must develop skills in spiritual care and be able to do so with patients from different cultures and different spiritual and religious backgrounds, particularly at the end of life. This article describes the experience of successfully introducing a curriculum on spirituality and multicultural literacy into the required Family Medicine Clerkship at Stanford University School of Medicine. Rather than a program of separate classes on spirituality, culture, and end-of-life care, an effective curriculum includes a matrix of learning activities that address: 1) a cross-cultural approach to spiritual needs, 2) spirituality at the end of life, 3) the impact of cultural values at the end of life, 4) the ways in which cultural and spiritual needs interact at the end of life, and 5) the interface between medical culture and a patient's culture. Integrating spirituality and culture with end-of-life care into the fabric of the medical school curriculum is an essential step toward serving our increasingly multicultural and multireligious society.     

Shaping End-of-Life Care: Behavioral Economics and Advance Directives

A central but unmet challenge in health care delivery is to increase the probability that the care patients receive near the end of their life is consistent with their goals, values, and preferences. Providing patient-centered care at the end of life is challenging. In their final days, nearly a third of older Americans need critical decisions made regarding the use or nonuse of life-sustaining interventions, but the patients themselves cannot participate in those decisions. Although this observation highlights the promise of advance directives (ADs), to date ADs have not delivered on this promise. This article provides a new framework, based in behavioral economic theory, that may explain the current failures of ADs and point to potential solutions. Specifically, it discusses how five well-described cognitive biases that pervade human decision making (affective forecasting errors, optimism bias, present-biased preferences, focusing effects, and default options) may account for deficiencies in the uptake, efficacy, and patient-centeredness of ADs. The text suggests potential solutions in need of evaluation, discusses metrics for assessing these interventions' benefits, and considers alternatives to the approaches advocated.     

Preferences of Physicians and Their Patients for End-of-Life Care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7), African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.