scholarly journals Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Rhéda Adekpedjou ◽  
George A. Heckman ◽  
Paul C. Hébert ◽  
Andrew P. Costa ◽  
John Hirdes
Keyword(s):  
End Of Life ◽  
Long Term Care ◽  
Care Home ◽  
Do Not Resuscitate ◽  
Multistate Models ◽  
Term Care ◽  
Health Trajectories ◽  
Advance Care Directives ◽  
Advance Care

Abstract Background Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes. Methods In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015. Results We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively. Conclusion Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

scholarly journals Identifying Potentially Avoidable Emergency Department Visits of Long-Term Care Hospital Residents in Korea: A Multicenter Retrospective Cohort Study

2019 ◽  
Vol 2019 ◽  
pp. 1-7
Author(s):  
Keon Kim ◽  
Dong Hoon Lee ◽  
Ho Young Yune ◽  
Jung Hee Wee ◽  
Duk Ho Kim ◽  
...  
Keyword(s):  
Long Term Care ◽  
Emergency Department Visits ◽  
Care Hospital ◽  
Do Not Resuscitate ◽  
University Hospitals ◽  
Term Care ◽  
Number Of Patients ◽  
Advance Care ◽  
Dnr Orders

The aims of this study were to investigate the reasons of transfers from long-term care hospitals (LTCHs) to emergency departments (EDs) of university hospitals in geriatric patients and to categorize the avoidable causes of these transfers. This retrospective multicenter study involved patients aged 65 years and older who were transferred from LTCHs to 5 EDs of university hospitals located in the metropolitan area of South Korea between January 2017 and December 2017. The expert panel reviewed and categorized the reason of transfers as avoidable or not. Moreover, we also investigated the number of patients with do-not-resuscitate (DNR) documents and the date these DNR documents were written. A total of 255,543 patients visited 5 EDs during the study period. Of these, 1,131 patients were from LTCHs. The number of potentially avoidable transfers was 168/1,131 (14.9%). The most common reason of avoidable transfers was noncritical diagnoses that could be assessed and managed in LTCHs (57.1%). There were 162 patients with DNR orders; of these, 12 had approved the DNR order before transfer. In conclusion, in Korea, potentially avoidable transfers could be reduced by managing noncritical diseases in LTCH and preparing advance care directives, including DNR orders, during admission to LTCH.

scholarly journals Costs of inpatient hospitalisations in the last year of life in older New Zealanders: a cohort study

2021 ◽  
Author(s):  
Oliver Scott ◽  
Merryn Gott ◽  
Richard Edlin ◽  
Simon Moyes ◽  
Marama Muru-Lanning ◽  
...  
Keyword(s):  
End Of Life ◽  
Long Term Care ◽  
Care Home ◽  
Advanced Age ◽  
Term Care ◽  
Lengths Of Stay ◽  
And Gender ◽  
Minimum Dataset ◽  
New Zealanders

Abstract BackgroundRapidly ageing populations means that many people now die in advanced age. This paper investigated public hospital and long-term care home costs in the 12 months before death in Māori and non-Māori of advanced age in New Zealand.MethodsData from an existing longitudinal study (LiLACS NZ) was used, in which 937 older New Zealanders were enrolled in 2010. At the time of this study, 213 Māori and 241 non-Māori in the cohort had died. National Health Index numbers were linked to the hospitalisation National Minimum Dataset to ascertain public hospitalisation and care home costs in the last year of life. ResultsThe average total publicly funded hospital and long-term care home costs in the 12 months prior to death were $16,211 and $17,351 for Māori and non-Māori respectively. Non-Māori tended to have long lengths of stay in their last year of life, and non-Māori men had the highest proportion with high costs and long lengths of stay in care homes. Costs in the last year of life were 8.1 times higher in comparison to costs for individuals who did not die in the same time period. ConclusionDespite New Zealand’s commitment to providing an equitable level of healthcare, this study illustrated that ethnic and gender disparities are still apparent at the end of life. This raises questions as to whether money at the end of life is being spent appropriately, and how it could potentially be more equitably targeted to meet the diverse needs of older people and their families.

scholarly journals Costs of inpatient hospitalisations in the last year of life in older New Zealanders: a cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Oliver W. Scott ◽  
Merryn Gott ◽  
Richard Edlin ◽  
Simon A. Moyes ◽  
Marama Muru-Lanning ◽  
...  
Keyword(s):  
End Of Life ◽  
Long Term Care ◽  
Care Home ◽  
Advanced Age ◽  
Term Care ◽  
Lengths Of Stay ◽  
And Gender ◽  
Minimum Dataset ◽  
New Zealanders

Abstract Background Rapidly ageing populations means that many people now die in advanced age. This paper investigated public hospital and long-term care home costs in the 12 months before death in Māori and non-Māori of advanced age in New Zealand. Methods Data from an existing longitudinal study (LiLACS NZ) was used, in which 937 older New Zealanders were enrolled in 2010. At the time of this study, 213 Māori and 241 non-Māori in the cohort had died. National Health Index numbers were linked to the hospitalisation National Minimum Dataset to ascertain public hospitalisation and care home costs in the last year of life. Results The average total publicly funded hospital and long-term care home costs in the 12 months prior to death were $16,211 and $17,351 for Māori and non-Māori respectively. Non-Māori tended to have long lengths of stay in their last year of life, and non-Māori men had the highest proportion with high costs and long lengths of stay in care homes. Costs in the last year of life were 8.1 times higher in comparison to costs for individuals who did not die in the same time period. Conclusion Despite New Zealand’s commitment to providing an equitable level of healthcare, this study illustrated that ethnic and gender disparities are still apparent at the end of life. This raises questions as to whether money at the end of life is being spent appropriately, and how it could potentially be more equitably targeted to meet the diverse needs of older people and their families.

Challenges in implementing an advance care planning programme in long-term care

2016 ◽  
Vol 24 (1) ◽  
pp. 87-99 ◽  
Author(s):  
Ciara McGlade ◽  
Edel Daly ◽  
Joan McCarthy ◽  
Nicola Cornally ◽  
Elizabeth Weathers ◽  
...  
Keyword(s):  
End Of Life ◽  
Advance Care Planning ◽  
End Of Life Care ◽  
Long Term Care ◽  
Care Plan ◽  
Care Planning ◽  
Life Care ◽  
Term Care ◽  
Advance Care

Background: A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the ‘Let Me Decide’ advance care planning programme in long-term-care. Research design: This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval. Findings: Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training. Discussion: The challenges encountered were largely concerned with preserving resident’s autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources. Conclusions: Although it may be too late for many long-term-care residents to complete their own advance care directive, the ‘ Let Me Decide’ programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.

Medical orders for life-sustaining treatment: Is it time yet?

2013 ◽  
Vol 12 (2) ◽  
pp. 101-105 ◽  
Author(s):  
Anna Clarissa Araw ◽  
Anna Marissa Araw ◽  
Renee Pekmezaris ◽  
Christian N. Nouryan ◽  
Cristina Sison ◽  
...  
Keyword(s):  
New York ◽  
End Of Life ◽  
Median Time ◽  
Advance Directive ◽  
Long Term Care ◽  
Do Not Resuscitate ◽  
Cross Sectional ◽  
Term Care ◽  
Life Sustaining Treatment

AbstractObjective:As the aging population faces complex end-of-life issues, we studied the intervals between long-term care admission and advance directive completion, and between completion and death. We also sought to determine the interdisciplinary team's compliance with documented wishes.Method:A cross-sectional study of 182 long-term care residents in two facilities with and without completed medical orders for life-sustaining treatment (MOLST) in the New York Metropolitan area was conducted. Demographic variables included: gender, age, ethnicity, and diagnosis. Measures included: admission date, MOLST execution date, and date of death. Resident advance directive documentation was compared with clinical intervention at time of death, including intubation and mechanical ventilation.Results:Of the residents studied, 68.7% were female, 91% were Caucasian and 91.8% were ≥ 65 years of age (mean age: 83). The median time from admission to MOLST signing was 48 days. Median time from admission to MOLST signing for Caucasians was 21 days; for non-Caucasians was 229 days. Fifty-two percent of MOLST were signed by children, and 24% by residents. Of those with signed forms, 25% signed on day of admission, 37% signed within 7 days, and 47% signed within 21 days. Only 3% of residents died the day their MOLST was signed, whereas 12% died within a week, and 22% died within 30 days. Finally, among the 68 subjects who signed a MOLST and died, 87% had their wishes met.Significance of results:In this era of growing time constraints and increased regulations, medical directors of long-term care facilities and those team members caring for residents urgently need a clear and simple approach to the goals of care for their residents. The MOLST is an ideal tool in caring for older adults at the end of life, providing concrete guidance, not only with regard to do not resuscitate (DNR) and do not intubate (DNI) orders, but also for practical approaches to daily care for the interdisciplinary team.

scholarly journals Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes

2021 ◽  
pp. 1-11
Author(s):  
George A. Heckman ◽  
Veronique Boscart ◽  
Patrick Quail ◽  
Heather Keller ◽  
Clare Ramsey ◽  
...  
Keyword(s):  
End Of Life ◽  
Advance Care Planning ◽  
Long Term Care ◽  
Sufficient Information ◽  
Care Planning ◽  
Term Care ◽  
Health Crisis ◽  
Knowledge To Action ◽  
Advance Care

Abstract As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.

scholarly journals Complexity of Nurse Practitioners’ Role in Facilitating a Dignified Death for Long-Term Care Home Residents during the COVID-19 Pandemic

2021 ◽  
Vol 11 (5) ◽  
pp. 433
Author(s):  
Shirin Vellani ◽  
Veronique Boscart ◽  
Astrid Escrig-Pinol ◽  
Alexia Cumal ◽  
Alexandra Krassikova ◽  
...  
Keyword(s):  
End Of Life ◽  
Nurse Practitioners ◽  
End Of Life Care ◽  
Long Term Care ◽  
Care Home ◽  
Good Death ◽  
Life Care ◽  
Care Needs ◽  
Term Care

Due to the interplay of multiple complex and interrelated factors, long-term care (LTC) home residents are increasingly vulnerable to sustaining poor outcomes in crisis situations such as the COVID-19 pandemic. While death is considered an unavoidable end for LTC home residents, the importance of facilitating a good death is one of the primary goals of palliative and end-of-life care. Nurse practitioners (NPs) are well-situated to optimize the palliative and end-of-life care needs of LTC home residents. This study explores the role of NPs in facilitating a dignified death for LTC home residents while also facing increased pressures related to the COVID-19 pandemic. The current exploratory qualitative study employed a phenomenological approach. A purposive sample of 14 NPs working in LTC homes was recruited. Data were generated using semi-structured interviews and examined using thematic analysis. Three categories were derived: (a) advance care planning and goals of care discussions; (b) pain and symptom management at the end-of-life; and (c) care after death. The findings suggest that further implementation of the NP role in LTC homes in collaboration with LTC home team and external partners will promote a good death and optimize the experiences of residents and their care partners during the end-of-life journey.

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