Resident Death Research Articles

Learning, support and communication for staff in care homes: outcomes of reflective debriefing groups in two care homes to enhance end-of-life care.

Nursing care homes are increasingly the place where frail older people die. However, training in end-of-life care is not statutory. To develop strategies to promote quality end-of-life care in nursing care homes. Action research was used to work collaboratively with the managers and staff in two nursing care homes to develop end-of-life care. There were three overarching phases: an exploratory phase, feedback/planning of actions and a summative evaluation. Two main actions were inductively derived. One of the actions, reflective debriefing groups following a resident's death, is reported. Ten reflective debriefing groups, led by the researcher (a specialist palliative care nurse), were undertaken. The groups facilitated learning at three different levels (being taught, developing understanding and critical thinking) and enabled staff to feel supported and valued. The use of reflective debriefing groups is a useful mechanism to support experience-based learning about death/dying in care homes.

Survey of New York City Resident Physicians on Cause-of-Death Reporting, 2010

IntroductionDeath certificates contain critical information for epidemiology, public health research, disease surveillance, and community health programs. In most teaching hospitals, resident physicians complete death certificates. The objective of this study was to examine the experiences and opinions of physician residents in New York City on the accuracy of the cause-of-death reporting system.MethodsIn May and June 2010, we conducted an anonymous, Internet-based, 32-question survey of all internal medicine, emergency medicine, and general surgery residency programs (n = 70) in New York City. We analyzed data by type of residency and by resident experience in reporting deaths. We defined high-volume respondents as those who completed 11 or more death certificates in the last 3 years. ResultsA total of 521 residents from 38 residency programs participated (program response rate, 54%). We identified 178 (34%) high-volume respondents. Only 33.3% of all respondents and 22.7% of high-volume residents believed that cause-of-death reporting is accurate. Of all respondents, 48.6% had knowingly reported an inaccurate cause of death; 58.4% of high-volume residents had done so. Of respondents who indicated they reported an inaccurate cause, 76.8% said the system would not accept the correct cause, 40.5% said admitting office personnel instructed them to “put something else,” and 30.7% said the medical examiner instructed them to do so; 64.6% cited cardiovascular disease as the most frequent diagnosis inaccurately reported.ConclusionMost resident physicians believed the current cause-of-death reporting system is inaccurate, often knowingly documenting incorrect causes. The system should be improved to allow reporting of more causes, and residents should receive better training on completing death certificates.

COPD Surveillance—United States, 1999-2011

This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged ≥ 25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P = .019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P = .001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P = .045), among men (P = .022) and among enrollees aged 65 to 74 years (P = .033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P = .163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P < .001) and among American Indian/Alaska Natives (P = .008) but declined among those aged 55 to 64 years (P = .002) and 65 to 74 years (P < .001), Hispanics (P = .038), Asian/Pacific Islanders (P < .001), and men (P = .001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.

Grief Among Family Members of Nursing Home Residents With Advanced Dementia

To describe preloss and postloss grief symptoms among family members of nursing home (NH) residents with advanced dementia, and to identify predictors of greater postloss grief symptoms. Prospective cohort study. 22 NHs in the greater Boston area. 123 family members of NH residents who died with advanced dementia. Preloss grief was measured at baseline, and postloss grief was measured 2 and 7 months postloss using the Prolonged Grief Disorder Scale. Independent variables included resident and family member sociodemographic characteristics, resident comfort, acute illness, acute care prior to death, family member depression, and family member understanding of dementia and of resident's prognosis. Levels of preloss and postloss grief were relatively stable from baseline to 7 months postloss. Feelings of separation and yearning were the most prominent grief symptoms. After multivariable adjustment, greater preloss grief and the family member having lived with the resident prior to NH admission were the only factors independently associated with greater postloss grief 7 months after resident death. The pattern of grieving for some family members of NH residents with advanced dementia is prolonged and begins before resident death. Identification of family members at risk for postloss grief during the preloss period may help guide interventions aimed at lessening postloss grief.

Nursing Home Adverse Events: Further Insight into Highest Risk Periods

Adverse events (AEs) occur frequently in nursing homes (NHs). Although the literature identifies several AE risk factors, the effect of resident transition on AE risk is less well defined. This article is the first to describe how AE risk varies across several NH transition periods and to define the most vulnerable junctures of an NH stay. This research was conducted on the population of NH residents in Manitoba, Canada, from April 1, 1999, to March 31, 2004. AEs were captured using physician-based diagnostic claims for hip fractures, other fractures, hospitalized falls, skin ulcers, and respiratory infections. AE rates were compared across several transition periods (eg, following first NH admission from hospital versus elsewhere, after NH transfer, and preceding resident death), before and after adjustment for several resident demographic, clinical, and facility-level factors. Although residents (n = 22,846) spent only 6.6% of all NH days in transition, between 15.3% (skin ulcers) and 27.8% (respiratory infections) of AEs occurred during these times. Except following NH transfers, adjusted AE rates were consistently higher during all transition versus nontransition periods. Among transition periods, adjusted hip fractures, hospitalized falls, and respiratory infections were most strongly associated with resident death. Adjusted skin ulcer and non-hip fracture rates were equally highest during "pre-death" and for new residents admitted from hospital. This article is the first to identify the most vulnerable times of a NH stay. For newly admitted residents, our results also show that previous exposure to a hospital environment, and not simply resident illness, at least partially contributes to increased AE risk. This and additional evidence can help clinicians and administrators to better identify periods of high risk for NH residents, and also to develop more targeted care improvement strategies. More robust and frequently obtained measures of resident illness are required to further examine these issues in more detail.

Lessons From Nursing Facility Accidents

Lessons From Nursing Facility Accidents

Results and analysis on the national key monitoring of endemic arsenism in Jilin Province in 2005 and 2006

Objective To explore the present condition of endemic arsenism, the implementation of control measures and the effect of the monitored county (Tongyu County) and the monitoring spot (Baiyintuhai Village) in 2006 and 2007. Methods According to the National Survey Scheme of Endemic Arsenism, the progress of anti-arsenic water in Tongyu, and the management and running of all engineering projects and the arsenic content in water were surveyed. The patients with endemic arsenism in Tongyu were generally surveyed. The arsenic content of the improved drinking water in Tongyu and the arsenic in urine of children aged 8-12 and adults over 18 years of age were determinted. The causes of resident death in the monitoring spot from the year of 2006 and 2007 were investigated. Arsenic content of drinking water and the urine of local residents was examined with Model AFS-930 Double-Channel Atomic Fluorescence Spectrometer. Results There were 30 endemic arsenism areas, 157 areas with high arsenic content and all population of 57 576 in Tongyu. Six areas had improved water till 2006, where 20.0% of water had improved, and six water-improving projects were all running normally, benefiting a population of 1670. Eight high arsenic areas changed water, in a rate of 5.09%. Eight water-improving projects were functioning well, benefiting a population of 4350. Until 2007, 28 areas had improved water in Tongyu, accounting for 93.33%. These 28 projects were well running, covering a population of 7980. One hundred and fouty-eight high arsenic areas had changed water, reaching a rate of 94.27%. One hundred and fouty-eight projects changedg water were running normally, benefiting a population of 46 214. In the surveyed spots, arsenic content was between 0.004 mg/L and 0.005 mg/L in 2006 and between 0.010 mg/L and 0.021 mg/L in 2007, all in the normal range to the time being. The arsenic contents in urine of the children aged 8-12 in the monitoring spots were determinted, averaging at 0.024 mg/L in 15 samples, fluctuating between 0.005 mg/L and 0.048 mg/L in 2006. The average content in urine from adults was 0.019 mg/L in 53 samples, fluctuating between 0.005 mg/L and 0.087 mg/L in 2007. The arsenic contents in urine were all in the normal range in 2006 and 2007. In 2006 14 endemic arsenism patients, all in light symptoms, had been checked out, the morbidity being 6.19%. In 2007, 17 patients who were all in light symptoms were identified in a rate of 6.94%. There was no significant difference of morbidity between the two years(χ2=0.1059, P>0.05). Two patients died, unrelating with drinking high arsenic water in 2006 and 2007. Conclusions The prevention and control measures are well implemented in Tongyu. The water-improving projects are functioning well. The condition of endemic arsenism is slight and hasn't changed so much in these two years. The arsenic contents in urine of children and adults within the normal range, showing that improving water can control the occurrence and the development of endemic arsenism. Key words: Arsenic poisoning; Drinking; Environmental monitoring; Population surveillance

A New Model for Long-Term Care: Balancing Palliative and Restorative Care Delivery

ABSTRACT Nursing homes have been mandated to maintain or promote the physical and psychological functioning of residents since the enactment of the 1987 Omnibus Reconciliation Act. Although this restorative approach to care has improved outcomes for some residents (Institute of Medicine, 2001), it ignores the reality that all permanently placed residents will die. A new model for long-term care, one that includes a simultaneous restorative and palliative approach to care delivery, is proposed. Palliative care principles provide a guiding framework for changing care delivery. Basic tenets, such as resident and family viewed as a unit of care, interdisciplinary teamwork, and interdisciplinary plans of care, provide a basis for specific operational suggestions. Operational strategies, such as psychosocial and spiritual support for family, resident decision making and participation in goal setting, expertise in aggressive pain and symptom control, and bereavement services following resident death, are described.

Surviving the Storms: Emergency Preparedness in Texas Nursing Facilities and Assisted Living Facilities

This study assesses the preparedness of long-term care facilities in Texas responding to Hurricanes Katrina and Rita. A 41-item questionnaire was mailed to facilities; the response rate was 42%. Among responding facilities, 4513 residents were evacuated, and 6% of respondents reported resident death. Financial losses were reported by 8% of nursing facilities and 45% of assisted living facilities due to transportation and staff overtime. Respondents indicated the need for improved disaster preparednesstraining, better coordination, and transportation. Changes in policy and practice will lead to better trained staff who will provide the care residents need for improved health outcomes during future public health disasters.

Health Care Homicide? Or, Are Medical Errors Being Increasingly Criminalized?

Health Care Homicide? Or, Are Medical Errors Being Increasingly Criminalized?

Florida Assisted-Living Facility Is Perfect Lab for Young Filmmaker

Florida Assisted-Living Facility Is Perfect Lab for Young Filmmaker

Spatial patterns and covariates of heart disease death rates in Michigan, 1998-2004

Using the 1998 through 2004 data from the Michigan Resident Death Files, this paper examined the changing spatial patterns of heart disease death across Michigan counties and assessed the association between heart disease deaths and selected socioeconomic risk factors among people aged 50 years and older. Methods: Tertiles of low, medium, and high rates were derived for 3-year moving averages of heart disease death rates for the counties. Results: Overall, the mortality rates declined over time. Areas of low mortality rates expanded over time while the number of counties with high rates decreased. The regression analyses showed that primary level of education or less, unemployment rate, median household income, poverty rate, and lack of health insurance were each significantly associated with heart disease mortality. Conclusion: The difference in the spatial pattern of heart disease deaths across the counties suggests a significant difference in the distribution of the underlying factors in Michigan communities. While our results indicate that the socio-economic environment plays a significant role in heart disease mortality in the state, more researches are needed to investigate these factors at the individual level.

Arsenic in drinking water and cerebrovascular disease, diabetes mellitus, and kidney disease in Michigan: a standardized mortality ratio analysis

BackgroundExposure to arsenic concentrations in drinking water in excess of 300 μg/L is associated with diseases of the circulatory and respiratory system, several types of cancer, and diabetes; however, little is known about the health consequences of exposure to low-to-moderate levels of arsenic (10–100 μg/L).MethodsA standardized mortality ratio (SMR) analysis was conducted in a contiguous six county study area of southeastern Michigan to investigate the relationship between moderate arsenic levels and twenty-three selected disease outcomes. Disease outcomes included several types of cancer, diseases of the circulatory and respiratory system, diabetes mellitus, and kidney and liver diseases. Arsenic data were compiled from 9251 well water samples tested by the Michigan Department of Environmental Quality from 1983 through 2002. Michigan Resident Death Files data were amassed for 1979 through 1997 and sex-specific SMR analyses were conducted with indirect adjustment for age and race; 99% confidence intervals (CI) were reported.ResultsThe six county study area had a population-weighted mean arsenic concentration of 11.00 μg/L and a population-weighted median of 7.58 μg/L. SMR analyses were conducted for the entire six county study area, for only Genesee County (the most populous and urban county), and for the five counties besides Genesee. Concordance of results across analyses is used to interpret the findings. Elevated mortality rates were observed for both males (M) and females (F) for all diseases of the circulatory system (M SMR, 1.11; CI, 1.09–1.13; F SMR, 1.15; CI, 1.13,-1.17), cerebrovascular diseases (M SMR, 1.19; CI, 1.14–1.25; F SMR, 1.19; CI, 1.15–1.23), diabetes mellitus (M SMR, 1.28; CI, 1.18–1.37; F SMR, 1.27; CI, 1.19–1.35), and kidney diseases (M SMR, 1.28; CI, 1.15–1.42; F SMR, 1.38; CI, 1.25–1.52).ConclusionThis is some of the first evidence to suggest that exposure to low-to-moderate levels of arsenic in drinking water may be associated with several of the leading causes of mortality, although further epidemiologic studies are required to confirm the results suggested by this ecologic SMR analysis.

Medical Directors Are Key in Abuse Prevention

Medical Directors Are Key in Abuse Prevention

Perinatal Periods of Risk: Analysis of Fetal–Infant Mortality Rates in Kansas City, Missouri

The Perinatal Periods of Risk (PPOR) technique was used to analyze resident fetal and infant death data from Kansas City, Missouri, for the period 1998-2002. Results offer important information that can be used to develop community-based prevention strategies related to racial/ethnic disparities in infant mortality rates (IMR). The PPOR approach for fetal and infant mortality can be mapped by birthweight at delivery and time of death into four strategic prevention areas: 1) Maternal Health/Prematurity (MHP), 2) Maternal Care (MC), 3) Newborn Care (NC), and 4) Infant Health (IH). For this analysis, all fetal and infant death certificates from the metropolitan Kansas City area were linked to their birth certificates and those associated with residents of Kansas City, Missouri, proper were used to create the dataset used in this analysis. Due to the small number of fetal and infant deaths among other ethnic groups, the analysis was restricted to a comparison of the disparity of IMR between Blacks, Whites, and a national non-Hispanic white reference group. The Kitagawa formula was used to determine contribution to excess deaths from birthweight-specific mortality and birthweight distribution rates. Logistic regression techniques were used to identify risk factors for death among Black fetuses and infants with very low birthweights and also deaths due to sudden infant death syndrome (SIDS). The PPOR analysis showed that of the excess deaths among black infants, when compared to a national reference group, 47% was attributable to MHP and another 29% was attributable to IH. Differences in MC and NC only accounted for 27 and 8% of the total excess deaths. During the study period, rates of sudden infant death syndrome (SIDS) were found to be significantly higher among Blacks as compared to Whites (2.12 vs. 0.81 per 1,000). An analysis of maternal characteristics for SIDS deaths among blacks using a step-wise logistic regression model, found that maternal age less than 20 years old, previous births, inadequate prenatal care, and being a Medicaid recipient were significant-adjusted odds ratios of 23.7 (95% Cl 10.48, 53.67), 8.4 (95% Cl 3.64, 19.21), 2.9 (95% Cl 1.38, 6.05) and 2.5 (95% Cl 1.04, 5.84), respectively. PPOR is an easy to use approach that helps focus community initiatives for improving maternal and infant health. In Kansas City, Missouri, efforts to further lower IMR in blacks can be achieved through the reduction of risk factors affecting maternal health and through maternal education to improve infant health.

End-of-life care in a nursing home: a study of family, nurse and healthcare aide perspectives

To examine the perspectives of family members, registered nurses and healthcare aides regarding the last 72 hours of Canadian nursing home residents' lives. Exploratory, descriptive design using semistructured interviews. Consisted of 14 registered nurses and eight healthcare aides who had provided care within the last 72 hours before a resident's death and four family members who had visited within the same time frame. A 220-bed nursing home located within a larger long-term care facility in Canada. Thematic analysis was conducted independently and through consensus identified themes and subthemes emerging from the interviews. Dyspnea was a more common end-of-life (EoL) symptom for nursing home residents in this sample than was pain. Caring behaviours of staff were central to the resident's dying process and involved assessment, coordination of care, physical care, family education and nurture. Family members' ambivalence about the resident's death and fear of the resident dying alone were frequently noted. Appropriate and timely symptom management and a range of caring behaviours of staff are critical elements in the dying experience of nursing home residents. Additional education and support for personnel involved with caring for this group will enhance end-of-life care.

End-of-Life Issues for American Indians/Alaska Natives: Insights from One Indian Health Service Area

In the United States, the American Indian and Alaska Native (AI/AN) population is aging and the leading causes of death for those 55 and older are chronic diseases such as cancer, heart disease, and the complications of diabetes. Since 1955, the federally directed Indian Health Service, along with Tribal governments has been providing comprehensive health care to over 500 AI/AN communities. This is the first study to examine end-of-life and palliative care issues broadly at selected Indian Health Service facilities in the Albuquerque area. Retrospective medical records review identified from randomized New Mexico Department of Health American Indian resident death certificates, 50 years of age and over, from 1994-1998. Interviews with hospital administrators, medical records personnel, and cultural advisors regarding end-of-life policies and procedures were conducted. The study documents very limited formal palliative care services available to rural and reservation-dwelling American Indians and Alaska Natives. However, new initiatives and training in palliative care are emerging. Recommendations for fostering expansion of end-of-life and palliative care services for AI/AN persons are discussed.

Evaluation of emergency medicine resident death notification skills by direct observation.

Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications. To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents. This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000-visit community teaching hospital emergency department. There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third-year EM residents and female EM residents were more likely to be rated excellent. Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.

Evaluation of Emergency Medicine Resident Death Notification Skills by Direct Observation

AbstractEmergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications. Objective: To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents. Methods: This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000‐visit community teaching hospital emergency department. Results: There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third‐year EM residents and female EM residents were more likely to be rated excellent. Conclusions: Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.

Implementing an Effective in House Food Safety-Training Program Forrkitchen Workers

Health care facilities can benefit in many ways by implementing an “in house” food safety training program that evaluates employee knowledge pertaining to food safety, effectively educates staff, and monitors knowledge put to use in daily practice. Safe food handling in the health-care setting is paramount among dietary employees due to the susceptible population they serve. The elderly, sick, and the immuno compromised patients are the most “at risk” populations for acquiring food borne disease. By pretesting employees, offering training modules, post testing, and reinforcing safe food handling techniques in the workplace, food service operators can be assured they are lowering the risk of spreading food borne disease. An improved sense of purpose and enhancement of professional skills are two positive employee outcomes. The program's primary components were developed from topics in the National Restaurant Association's ServeSafe food safety certification course text book. Priority topics were chosen from leading causes of food borne disease such as improper cooling of cooked foods, improper heating and reheating, inadequate personal hygiene, and food cross contamination. As food safety concepts such as Hazard Analysis, Critical Control Points (HACCAP) become mandated, the need to adequately educate the kitchen staff becomes crucial. With a commitment from the top, food safety training costs can be controlled, outbreaks of food borne disease can be minimized, premature resident death due to food poisoning can be averted, and facilities can remain financially solvent while maintaining a positive reputation in the community.