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Cross-sectional study
Nursing home residents prefer fewer interventions and the nursing home instead of hospital for place of death
  1. Julie Watson
  1. Edinburgh Centre for Research on the Experience of Dementia, University of Edinburgh, Edinburgh, UK
  1. Correspondence to: Dr Julie Watson, School of Health in Social Sciences (Nursing Studies), University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK; Julie.Watson{at}ed.ac.uk

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Implications for practice and research

  • End-of-life care preferences of residents in nursing homes confirm the importance of developing practice to ensure high-quality end-of-life is delivered.

  • The role and competencies required of nurses working in nursing homes in supporting the end-of-life preferences of residents requires more research.

Context

The importance of nursing homes as places where people die, and the need to support nursing homes to deliver end-of-life care, is increasingly recognised in many countries. Advance care planning (ACP), including identifying preferences for medical interventions, cardiopulmonary resuscitation (CPR) and preferred place of death, is a key facet of a palliative care approach and a pre-requisite to achieving quality end-of-life care. Ng and colleagues identify nursing home resident characteristics associated with ACP preferences in Project CARE (Care At the end-of-life for Residents in homes for the Elderly), a 3-year pilot programme introducing palliative care to nursing homes in Singapore.

Methods

A cross-sectional study design was used to examine data from 600 ACP discussions across seven nursing homes with residents with an estimated 6–12-month prognosis taking part in Project CARE. Project CARE is a collaboration between a hospital, a hospice, the Ministry of Health and the Agency for Integrated Care. It provides palliative care, including ACP, symptom management and nursing home staff training on palliative care, through visits by geriatric physicians, nurses and social workers to nursing homes. ACP discussions were usually conducted with the residents, their next-of-kin, nursing home staff and the Project CARE team from the hospital. Issues discussed included residents' values, and their end-of-life care preferences including medical interventions, CPR and preferred place of death. Statistical associations between a range of characteristics of residents, such as sociodemographic factors and levels of functional performance, and preferences for medical interventions, CPR and preferred place of death, were examined.

Findings

More than 50% of residents were aged >85 years old, the majority were totally dependent and >80% had cognitive impairment. In total, 52.3% preferred limited additional medical intervention at the nursing home or hospital, with those aged >85 years significantly more likely to prefer medical intervention at the nursing home. In total, 93.2% opted against CPR. A greater proportion of those who preferred not to have CPR were aged >85 years, were severely dependent and had neurodegenerative conditions. Seventy-seven per cent preferred to die in the nursing home which was significantly associated with being single and being Christian/Catholic rather than Buddhist or Taoist.

Commentary

Characteristics of residents in this study, in terms of age profile, morbidity, level of dependency and the need for end-of-life care reflect the characteristics of nursing home residents elsewhere including the UK.1 The findings from this study show that preferences for this profile of residents include limited medical interventions in the nursing home rather than the hospital, Do Not Attempt Resuscitation, and the nursing home as the preferred place of death. Despite the different geographical context, the similar profile of residents provides evidence for other countries of the importance of asking people what matters to them at the end of life, and the need for the extension of palliative care services to meet the needs and provide continuity of care for people in nursing/care homes.

In relation to medical intervention, Ng and colleagues in their discussion note that, while those residents who were aged >85 years preferred medical intervention at the nursing home rather than the hospital, overall more than half of residents and/or family members chose limited additional intervention at the nursing home and the hospital. The authors recognise the uncertainty this points to in making a choice between what is usually practised but not necessarily desirable (medical management at the hospital) versus what is new (ie, a new palliative care service) but more desirable (medical management at the nursing home). Although not mentioned in the paper, this uncertainty and the complexity of end-of-life decision-making underlines the importance of having nurses within care homes who have the knowledge and competencies, including communication skills, to ensure that the needs of residents are met and to minimise ‘avoidable’ transitions to acute care. Although palliative care programmes have been recognised as important in nursing/care homes in other countries such as the UK for some time, the role of nurses working in care homes remains unclear.2 Research to confirm and promote this role is warranted.

References

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.