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.     

Nursing home practice. Strategies to manage most acute and chronic illnesses without hospitalization

Physicians who practice in the nursing home often must decide whether to hospitalize a patient with an acute illness or provide on-site treatment. Most medical problems--including urinary tract infection, pneumonia, venous thromboembolism, and exacerbations of congestive heart failure--can be successfully managed in the nursing home. An aggressive primary care approach can improve the quality of care for vulnerable older patients, reduce the need for hospitalizations, and make nursing home practice more efficient and satisfying. Most dying patients can also receive the bulk of their medical and palliative care in the nursing home.     

An outbreak of giardiasis in a nursing home with evidence for multiple modes of transmission

During a 6-w period from 20 April through 7 June 1986, an outbreak of giardiasis occurred in residents and employees of a nursing home and children participating in day care at the nursing home. Eighty-eight cases of giardiasis (defined by presence of clinical symptoms or results of stool examination) were identified from groups associated with the nursing home including 35 in nursing home residents, 15 in children in day care, and 38 in employees (including kitchen staff and child care providers). Multiple modes of transmission of Giardia lamblia, including food-borne and person-to-person transmission, occurred for these groups. Evidence of transmission by food included a significant association between sandwich consumption and illness in nursing home staff (P = .04) and a significant lack of illness among nursing home residents who consumed only a pureed diet (P = .007), where all food items are cooked before serving. The primary case among the food handlers, whose illness began in mid-April, had an infected child in the day care center. Person-to-person transmission is supported by a significant association between illness and physical contact with children from the day care facility through an "adopted grandparent" program (P = .03). This is the first reported outbreak of giardiasis in a nursing home, and these findings have implications for disease control in other facilities that combine child day care and care of the elderly.     

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Psychiatric disorders among nursing home residents. Depression, anxiety, and paranoia

The number of people in nursing homes is growing at a rapid rate as the population includes greater numbers of elderly Americans. Psychiatric disorders, including depression, anxiety, and paranoia, are commonly seen among this group. Recognition and treatment of these disorders by health care professionals can improve the quality of care and quality of life for elderly nursing home residents.     

Do we need to create geriatric hospitals?

During a single illness episode, the sickest, frailest older patients are often treated in multiple distinct sites, including the emergency room, the intensive care unit, a general medical floor, and a skilled nursing facility. Such frequent transfers involve changes in physician, changes in nursing care, the rewriting of orders, and physical dislocation, all of which can adversely affect outcomes. This system, although efficient, increases the chance of medical errors, promotes delirium, and undermines the doctor-patient relationship. Partial solutions include a team approach to care, an electronic medical record, and substitution of home for hospital care. A more comprehensive solution is to create a geriatric hospital for treatment of the most common medical and surgical problems and for provision of rehabilitative or skilled nursing care. Designing new institutions for geriatric care will require new legislation and a new set of regulations but should be considered for the oldest and frailest patients.     

Effects of a care protocol on care outcomes in older nursing home patients with chronic obstructive pulmonary disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Matched, randomized case-control trial. SETTING: Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. PARTICIPANTS: Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. INTERVENTION: Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. MEASUREMENTS: Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. RESULTS: Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. CONCLUSION: Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.     

A population-based study of assessed applicants to long-term nursing home care.

OBJECTIVE: To examine the characteristics of all individuals assessed as requiring nursing home care arising from a population living within a defined geographical region and to study the manner in which they presented for assessment. DESIGN: Clinical assessment by a physician in geriatric medicine with the assistance of other disciplines. SETTING: Regional Geriatric Assessment Service. SUBJECTS: All persons recommended for nursing home care within the study period. RESULTS: The major diseases contributing to the need for nursing home care were organic brain disorders (60%) and stroke (32%). Dementia was present in 64% of cases; significant behavioral disturbance in 18%; severe communication disorders were frequent. The majority (86%) had been ill for greater than 1 year. The mode of presentation was acute in 9%, acute-on-chronic in 46%, and chronic in 45%. It was associated with significant differences in case characteristics including the location at the time of assessment, diagnoses, duration of illness, physical dependency, communication disorders, behavioral disturbance, and skilled nursing care requirements. CONCLUSIONS: These observations suggest that progression to nursing home care varies considerably. Strategies directed toward the prevention of institutionalization should be organized in recognition of these variations.     

Advance care planning for fatal chronic illness: avoiding commonplace errors and unwarranted suffering

Patients with eventually fatal illnesses often receive routine treatments in response to health problems rather than treatments arising from planning that incorporates the patient's situation and preferences. This paper considers the case of an elderly man with advanced lung disease who had mechanical ventilation and aggressive intensive care, in part because his nursing home clinicians did not complete an advance care plan and his do-not-resuscitate order did not accompany him to the hospital. The errors that led to his hospitalization and his unwanted treatment there demonstrate how the ordinary lack of advance care planning is deleterious for patients who are nearing the end of life. We discuss serious, recurring, and generally unnoticed errors in planning for care near the end of life and possible steps toward improvement. Repairing these shortcomings will require quality improvement and system redesign efforts, methods familiar from patient safety initiatives. Reliable improvement will also require making it unacceptable for clinicians to fail to plan ahead for care during fatal chronic illness.     

Older persons' preferences for site of terminal care.

BACKGROUND: Little is known about patients' preferences for site of terminal care. OBJECTIVE: To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN: Cross-sectional quantitative and qualitative interviews. SETTING: Participants' homes. PATIENTS: Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS: Preference for site of terminal care and the reasons for that preference. RESULTS: In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS: Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.     

A prospective study of acute illness in the nursing home

Managing acute illness is an important aspect of medical care for nursing home residents, but little data is available on the nature of acute illness in this setting. The aims of this study were to determine the incidence, etiologies, risk factors and outcomes of acute illness in nursing home residents. This was a prospective cohort study of residents at one Veterans Administration nursing home (N = 140). Acute illness episodes were identified prospectively for one year through staff interviews and medical record review. Etiologies of acute illness were determined based on standardized criteria. Subjects were followed for three years to determine hospital utilization, discharge location and survival. There were 113 acute illness episodes identified (0.59 episodes per subject per month). The most common etiologies were pneumonia (33% of episodes), and urinary tract infection (27%). Significant risk factors for acute illness included anemia, dependence in mobility and surveillance time (i.e., duration of time monitored for illness episodes) in the nursing home (model chi 2 27.16, p < 0.001). Subjects who developed acute illness had increased hospital utilization during the first year of follow-up (p = 0.034); they were also less likely to be discharged home by both one year (chi 2 12.37, p < 0.001) and two years of follow-up (chi 2 9.45, p = 0.009). When hospice and respite residents with short stay were excluded, subjects who developed acute illness had lower 3-year survival (Log rank 4.97, p = 0.026), and the rate of acute illness episodes (i.e., number per month monitored) predicted 3-year mortality (Cox proportional hazards, p < 0.001). In conclusion, acute illness is extremely common among nursing home residents, and is most often due to infection. The occurrence of acute illness identifies residents who have increased hospital utilization, are less likely to return home, and have decreased long-term survival.     

Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument

BACKGROUND: Acute illness causes considerable morbidity and mortality in nursing home residents but is often difficult to recognize early. Nursing assistants often notice early signs of acute illness but do not methodically document or communicate their observations with medical staff. OBJECTIVE: To enhance nursing assistants' observation and documentation of signs of acute illness by developing a validated, standardized instrument for communication with medical staff. DESIGN: Observational cohort study. SETTING: Urban not-for-profit nursing home. SUBJECTS AND METHODS: Candidate instrument items were generated in focus group interviews with nursing home staff. Twenty-three nursing assistants completed the instrument on 74 nursing home residents over 4 weeks. Acute illness, the primary outcome, was identified by nurse report and chart review and determined according to preset criteria. MEASUREMENTS: Predictive validity was assessed by determining the relationship between instrument responses and development of acute illness within 7 days. Interobserver agreement was calculated between morning and afternoon nursing assistants' responses. Convergent validity was assessed by comparing instrument responses with three standard status indicators. RESULTS: The instrument consisted of 12 items that assessed behavioral and functional status changes. Residents with an instrument-recorded change were more likely to develop an acute illness within 7 days than those with no change (risk ratio 4.1, 95% confidence interval 2.6, 6.3). A final five-item instrument had a sensitivity of 53% and a specificity of 93% for acute illness. Nursing assistants' documentation of signs of illness preceded chart documentation by an average of 5 days. Interobserver agreement between morning and afternoon nursing assistants was 76%. Correlation of responses with standard indicators of functional, mental, and global status was high. CONCLUSIONS: A new instrument developed for nursing assistants to document behavioral and functional status changes in nursing home residents demonstrates fair sensitivity and high specificity for acute illness. Close monitoring of patients with a positive instrument might avert morbidity and mortality from acute illness by allowing earlier treatment.     

Mental health services and the mortality of nursing home residents

This article examines the impact of mental health services on the mortality rate for mentally ill nursing home residents. Previous research has documented the unmet need for mental health services among nursing home residents. Some research using small data sets has indicated patient benefits from treatment. This article examines the issue using data from the nationally representative National Nursing Home Survey. In a series of multivariate logistic regressions, treatment for mental illness provided by either general practice physicians or by mental health specialists appears to have few impacts on mortality. A statistically significant treatment effect is found only for residents with schizophrenia, other psychoses, or anxiety disorders when treated by mental health specialists. The results are discussed with reference to ongoing reforms for mental health care in nursing homes.     

Decisions to withhold treatment from nursing home residents

Although the ethical issues in clinical care of severely impaired elderly nursing home residents may appear to be the same as those encountered in the acute hospital, they are not. In particular, "do not resuscitate" orders are not of central importance in the nursing home. For the individuals being considered, decisions about limiting routine treatments and whether treatment should include hospitalization are crucial. Establishing an ethical issues team is one means of increasing awareness of ethical issues in patient care and of dealing with these difficult issues more successfully.     

The prevalence and management of heart failure in Dutch nursing homes; design of a multi-centre cross-sectional study

ABSTRACT: BACKGROUND: Heart failure is likely to be particularly prevalent in the nursing home population, but reliable data about the prevalence of heart failure in nursing homes are lacking. Therefore the aims of this study are to investigate (a) the prevalence and management of heart failure in nursing home residents and (b) the relation between heart failure and care dependency as well as heart failure and quality of life in nursing home residents METHODS: Nursing home residents in the southern part of the Netherlands, aged over 65 years and receiving long-term somatic or psychogeriatric care will be included in the study. A panel of two cardiologists and a geriatrician will diagnose heart failure based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. Care dependency will be measured using the Care Dependency Scale. To measure the quality of life of the participating residents, the Qualidem will be used for psychogeriatric residents and the SF-12 and VAS for somatic residents. CONCLUSION: The study will provide an insight into the actual prevalence and management of heart failure in nursing home residents as well as their quality of life and care dependency. Trial registration: Dutch trial register NTR2663.     

Custodial nursing home care. Setting realistic goals

Despite concerted effort to rehabilitate and return patients to their homes, the majority of nursing home patients are destined to spend the remainder of their days in institutional settings. These custodial care patients are elderly, have many functional disabilities, and are often demented. The traditional medical approach to care, which emphasizes diagnosis and treatment of specific diseases, is often not appropriate for these patients. Instead, physicians should focus their attention on functional assessment and treatment, nontechnologic management of acute problems, humane terminal care, and the development of an efficient caregiving system within the nursing home.     

Influenza. How to prevent and control nursing home outbreaks.

Influenza is an important cause of acute respiratory illness among older adults in general and within the nursing home in particular. Epidemics typically are reported in the late fall and throughout the winter. In the nursing home, vaccination may not prevent clinical illness but can reduce the risk of pneumonia, hospitalization, and death. Atypical presentations, including delirium and nonspecific functional changes, are common in older patients. Rapid diagnosis is imperative, as early antiviral treatment and prophylaxis can control a nursing home outbreak.     

糖尿病延伸护理与居家护理干预对糖尿病患者生活质量和护理满意度的影响

目的研究糖尿病延伸护理和居家护理干预对糖尿病患者生活质量与护理满意度的相关影响。方法选取该院内分泌科2018年9月—2019年5月收治的85例糖尿病患者作为研究对象,按入院编号的单双数将85例糖尿病患者分为对照组(单数)和观察组(双数),其中对照组43例,观察组42例。给予对照组患者常规方法进行护理干预,而观察组患者则是在对照组基础上使用糖尿病延伸护理和居家护理干预,对两组患者护理结束后的生活质量和护理满意度进行比较。结果护理结束后,观察组患者的生活质量评分和护理满意度评分与对照组患者相比,数据差异有统计学意义(P<0.05)。结论糖尿病延伸护理和居家护理干预能够有效提高糖尿病患者的生活质量和护理满意度。     

Association Between Pneumonia and Oral Care in Nursing Home Residents

Pneumonia remains the leading cause of death in nursing home residents. The accumulation of dental plaque and colonization of oral surfaces and dentures with respiratory pathogens serves as a reservoir for recurrent lower respiratory tract infections. Control of gingivitis and dental plaques has been effective in reducing the rate of pneumonia but the provision of dental care for institutionalized elderly is inadequate, with treatment often sought only when patients experience pain or denture problems. Direct mechanical cleaning is thwarted by the lack of adequate training of nursing staff and residents’ uncooperativeness. Chlorhexidine-based interventions are advocated as alternative methods for managing the oral health of frail older people; however, efficacy is yet to be demonstrated in randomized controlled trials. Development and maintenance of an oral hygiene program is a critical step in the prevention of pneumonia. While resources may be limited in long-term-care facilities, incorporating oral care in daily routine practice helps to reduce systemic diseases and to promote overall quality of life in nursing home residents.     

Investigation of death clusters in a nursing home

The number of elderly residing in, and dying in, nursing homes is steadily increasing. In 1985, an investigation by the California attorney general's office was undertaken concerning a cluster of deaths in a single rural nursing home. The purpose of this study was to provide information for the investigation. The objectives of the study were to determine if there were excess deaths in the nursing home, and if so, to describe the circumstances surrounding the deaths and the policy implications for the quality of care in nursing homes. All the medical records for patients who died in a single nursing home between January 1, 1983 and April 30, 1985 were examined by the research team. Medical care was compared to desirable standards of care. A majority of the deaths, 52.5%, had major discrepancies from standard care that may have contributed to the patient's death. There were also major discrepancies in the cause of death between the death certificate and evidence from examination of the medical records. The data substantiated an unusual occurrence of deaths in the nursing home at the end of 1983 and again in early 1985, but no single factor or person could be identified as the major cause of the deaths. Although this is an isolated study of one nursing home, it is likely that these problems are not unique and the evaluation approach may be useful in other settings. It is recommended that nursing home deaths be routinely monitored, and that an unusual number of deaths should trigger an extensive investigation.