Palliative care consultation (PCC) during hospitalization is increasingly common for older adults with life-limiting illness discharged to nursing homes. Little is known about the consistency between PCC recommendations and post-discharge care. The purpose of this analysis was to describe the care trajectories and experiences of older adults admitted to a nursing home following a hospitalization during which they received a PCC. We recruited a sample of 12 adults over 60 years for this qualitative descriptive study. Care trajectories were mapped using information from medical record audits at five time points from hospital discharge to 100 days following nursing home admission. Interviews (n=15) with participants and surrogates were combined with each participant’s medical record data and care trajectory. Content analysis was employed on the combined dataset. All PCC referrals in this sample (mean age=80 years) were for goals of care conversations during which the PCC team discussed poor prognosis and recommended palliative approaches. All were admitted to a nursing home under the Medicare Skilled Nursing Facility Benefit. Re-hospitalization was common (n = 7); half of the sample lived an average of 19 days. Our analysis revealed three trajectory types: Focus on Rehabilitative Care, Patient–Family Caregiver Incongruence, and Comfort Care. Our findings suggest that there is poor congruence between PCC recommendations and post-discharge care. Heavy emphasis on recovering functional status through rehabilitation and skilled nursing care despite poor prognosis was identified. Future research should focus on predicting outcomes of rehabilitation and ways to incorporate this information in goals of care discussions.
Over 25% of older adults and almost 70% of persons with advanced dementia live out their final days in nursing homes. While the number of hospice patients living in nursing homes has increased dramatically over the past decade, other comprehensive palliative care models have not been widely adopted or tested in nursing homes. Palliative care nurses play critical roles in collaborating with nursing home staff to enhance end-of-life care and outcomes for older persons.
Abstract Elderly people represent the majority of patients affected by many serious and life-threatening illnesses. Population shifts have created an unprecedented demand for new models of palliative care for elderly patients at the end of life. The long-term care or nursing home setting is a vital site for improved care because ever-increasing numbers of elders are cared for here. There are many challenges in geriatric palliative care delivery in long-term care, including the availability of staff trained in palliative care and the management of frail elders with many comorbidities. However, the need for high-quality long-term care is significant. This chapter reviews some advances in long-term care and needs for continued improvement.
Refractory pain is an elusive and often misunderstood symptom in palliative care. Often, persistent pain, labeled as refractory, requires more complex assessments and interventions than the physical symptom of pain. Proper assessment of the “whole person” can reveal psychological, social, spiritual, or existential concerns that contribute to the experience of pain. The purpose of this article is to review and present evidence, guidelines, and recommendations for treating older adults with suspected refractory pain. This case-based illustration of pain is specifically focused on the older adult who is suspected of having refractory pain and has undergone care setting transitions between the hospital and nursing home and provides strategies for clinicians in both settings to best assess and meet patient needs. Recognition, assessment, treatment, and goal-directed nursing implications are presented.
Abstract Recognized globally, social activities support better quality of life in older adulthood. The COVID-19 pandemic presented unprecedented challenges for nursing homes (NHs) in balancing infection prevention control (IPC) measures with honoring resident preferences for social activities. The purpose of this study was to explore NH staff’s risk perceptions around facilitating resident preferences amidst pandemic restrictions. Guided by the Preference-Based Person-Centered Risk Engagement Model, this study used mixed methods to achieve an in-depth understanding NH staff risk perception. Quantitative data included demographics and risk perceptions using the Risk Propensity Scale. Participants (N=24) were 39 years on average (range: 18-62), mostly female (88%) and white (79%). Purposive sampling reflected a range of roles within the NH context: certified nursing assistants (29%), activities directors (25%), social workers (25%), and nurses (21%). Average risk perceptions scores were in the risk avoider range at 3.53 (SD = 1.43; range: 1.00-7.14) and most participants (58%) self-identified as risk avoiders. Those who identified as risk seekers were significantly more likely to be male (chi-sq(2)=17.14, p<.01) and African American (chi-sq(4)=20.42, p<.01). Qualitatively, semi-structured individual interviews collected staff perceptions of risk related to residents’ social activities. Guided content analysis revealed two main themes supported by six sub-themes: Factors of decision-making (family influence, organizational, staff and resident characteristics) and Direct care staff influencing preference-based care (cognitive skills and technical skills). Findings will be discussed considering implications for how best to support direct-care staff with varied perceptions of risk (risk seekers/risk avoiders) to encourage social activities when IPC measures are indicated.
Current palliative care workforce projections indicate that the growing palliative care needs of older adults in US nursing homes cannot be met by specialists, leaving them vulnerable and at risk for poor end-of-life outcomes. The purpose of this article is to describe the development, implementation, and initial evaluation of a program to support primary care nursing home nurse practitioners (NPs) in palliative care. The program aimed to improve geriatric NPs' knowledge and skills related to palliative care and to provide a structured protocol for integrating palliative care encounters into NPs' practice. It comprised three phases consisting of asynchronous online learning modules, a 1-day face-to-face communication skills and patient simulation workshop, and ongoing monthly virtual meetings to support NP clinical practice. Over a 1-year period, the program was developed and implemented with 12 practicing NPs in a national organization. Through an online survey and face-to-face feedback, NPs reported satisfaction with the curriculum and expressed it as valuable to their clinical practice. Future work will focus on sustaining implementation of the program, measuring patient level outcomes, and refining the curriculum based on NP feedback.
