Care Planning In Nursing Homes Research Articles

Conceptual Confusion: A Barrier to Multi-Professional Involvement in Advance Care Planning in Nursing Homes - An Ethnographic Study.

How health and social care professionals need to work together to deliver advance care planning (ACP) in nursing homes is not fully understood, with a reliance on professionals external to the nursing home to support ACP in the United Kingdom. The objectives of this study were to (a) examine the factors that influence multi-professional involvement in the ACP process within nursing homes and (b) explore how multi-professional working impacts the ACP process in nursing homes. Using ethnography, data was collected through observation, interviews and document review from 36 participants including residents (n = 6), relatives (n = 4), nursing home staff (n = 19) and visiting professionals (n = 7). Data analysis combined thematic analysis, mapping of ACP trajectories for participant residents, and documentary analysis of nursing home policies. There was conceptual confusion around ACP. How ACP was understood and what was prioritised for inclusion varied between residents and professionals, and between different professionals. That ACP was frequently integrated with routine care planning was not recognised in how professionals accounted for their ACP practice. Professionals prioritised biomedical concerns, despite this not reflecting resident priorities and policy suggesting a broader definition. This created difficulties in enacting ACP, with a holistic understanding of resident wishes not always captured. A shared understanding of ACP was not consistently evident from those tasked with its enactment. This, combined with professional construction of ACP in biomedical terms, limits multi-professional working and can prevent a person-centred process being achieved for nursing home residents.

Advance Care Planning in Nursing Homes: Comparing Characteristics and Outcomes of Participants and Non-Participants

Background There is an increasing need to integrate Advance Care Planning (ACP) in nursing homes (NH) due to rapid aging and burden of multimorbidity. This study examines differences in the characteristics and outcomes of NH residents enrolled in a palliative care programme who have completed ACP and those who did not. Method We conducted a retrospective cohort analysis of 294 deceased residents enrolled into a palliative programme from 8 nursing homes in Singapore. Comparison was made between residents who completed an ACP and those who did not. Treatment preferences and place of death preferences were examined and concordance to these preferences were analyzed. Results ACP completion rate was 81% in the cohort. Residents opting for comfort measures only had high concordance (92%) for their preferred place of death (PPOD). However, residents opting for limited intervention showed lower PPOD concordance (77%), with many dying in hospitals despite a preference for dying in the NH. Residents with ACP were significantly more likely to die in NH (68.2% vs. 36.4%) and had a longer median programme enrolment duration (131 vs. 53 days) compared to those who did not complete ACP. Conclusion Despite high ACP completion rate in our cohort, challenges remain in aligning treatment preferences with actual care provided, particularly for residents opting for limited intervention. Future efforts should focus on increasing ACP participation and addressing systemic barriers to improve end-of-life care outcomes for NH residents.

Advance Care Planning in Nursing Homes and Assisted Living Communities

To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP. After-death interviews of family members of decedents and facility liaisons where decedents received care. Stratified sample of 164 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. Family members and facility liaisons who gave 446 and 1014 reports, respectively, on 1015 decedent residents. Reports of death/dying discussions, known treatment preferences, and reports and records of signed living wills (LW), health care powers of attorney (HCPOA), do-not-resuscitate orders, and do-not-hospitalize orders. Family respondents reported a higher prevalence, compared with facility reports, of HCPOAs (92% versus 49%) and LWs (84% versus 43%). In family reports, non-white race and no private insurance were significantly associated with lower prevalence of LWs and HCPOAs; additionally, residing in nursing homes (versus assisted living facilities) and in North Carolina were associated with lower prevalence of reported LWs. In facility reports, non-white race, unexpected death, and residing in North Carolina or Maryland were significantly associated with lower prevalence of LWs, whereas high Medicaid case mix, intact cognitive status, and high family involvement were associated with lower prevalence of HCPOAs. Concordance of family and facility reporting of HCPOAs was significantly greater in facilities with fewer than 120 beds. The prevalence of ACP in LTC is much higher than previously described, and there is marked variation in characteristics associated with ACP, despite moderately high concordance, when reported by the facility or family caregivers.

Advance care planning in nursing homes: correlates of capacity and possession of advance directives.

The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors. Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged. Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.

Education and Advance Care Planning in Nursing Homes: The Impact of Ownership Type

The study examined the association between ownership type and community benefit as measured by organizational approaches to patient, family, and community education. As a case study of the broader class of educational efforts, the inquiry focused on educational efforts regarding a central patient care issue for nursing homes: the use of life-sustaining medical treatment. Results indicated that nonprofit and for-profit nursing homes were equally likely to conduct educational efforts concerning advance care planning. However, nonprofit nursing homes were more likely than for-profit nursing homes to have ongoing, rather than sporadic, discussions about advance care planning; to broaden such discussions beyond life-support wishes; and to have ethics committees to support advance care planning. Other empirical research has demonstrated ownership differences in both cost and quality of care. This study offers new evidence regarding additional ways in which nonprofit long-term care facilities may be distinguished from their for-profit counterparts.

Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey.

The Patient Self-Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision-making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states. Pre- and Post-observational cohort study. Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six-month follow-up was obtained at both time periods. Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a "Do Not Resuscitate" (DNR) order, a "Do Not Hospitalize" (DNH) order, or an order to forgo artificial nutrition or hospitalization. The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990. With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation.

Institutional efforts to promote advance care planning in nursing homes: challenges and opportunities.

In an empirical study of Connecticut-area for-profit and nonprofit nursing homes, authors examine use of institution-specific advance care planning forms among nursing home residents.