Effect of the Goals of Care Intervention for Advanced Dementia

Hanson, Laura C.; Zimmerman, Sheryl; Song, Mi‐Kyung; Lin, Feng; Rosemond, Cherie; Carey, Timothy S.; Mitchell, Susan L.

doi:10.1001/jamainternmed.2016.7031

Cited by 220 publications

(309 citation statements)

References 35 publications

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“…As in other advanced dementia studies involving primary data collection, 2,4,9 there was a high proxy refusal rate. Although preferences may have differed between proxies who did and did not participate, this possibility is less likely to have impacted the analyses examining factors associated with a preference for comfort care.…”

Section: Discussionmentioning

confidence: 64%

“…2,4 The present study suggests that embedded in that 95% are approximately one-third of proxies who would opt for basic medical care, which may include potentially curative treatments (e.g., antimicrobials) and hospitalization. The proportion of proxies strictly choosing comfort care (62%) was similar to that found in a comparable cohort when options were presented as three goals of care; “prolonging life, supporting function, or improving comfort.” 9 As in earlier research, 2,4,5,9 only a small proportion of proxies felt residents with advanced dementia should receive intensive medical care (6.5%).…”

Section: Discussionmentioning

confidence: 66%

“…2,4,9 Proxy refusal ( N = 672) was the only reason for non-participation. Non-participating and participating eligible residents did not differ with respect to age or gender.…”

Section: Resultsmentioning

confidence: 99%

“…Independent variables were selected from the EVINCE database that were felt “a priori” to be potentially related to a level of care preference based on the literature 2,4,5,7–9 and our clinical experience. Baseline resident data abstracted from the chart included demographics (age, gender, and race [white vs. other]), etiology of dementia (Alzheimer disease vs. other), and common comorbidities (chronic obstructive pulmonary disease, congestive heart failure, and diabetes).…”

Section: Methodsmentioning

confidence: 99%

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Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Mitchell

Palmer

Volandes

et al. 2017

Journal of Pain and Symptom Management

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Context Delivering goal-directed care is a hallmark of high-quality palliative care, but requires an understanding of preferences. Objectives To describe and identify factors associated with level of care preferences among proxies of nursing home (NH) residents with advanced dementia. Methods NH residents with advanced dementia and their proxies (N = 402 dyads) were recruited from 62 Boston-area facilities as part of an ongoing randomized clinical trial. At baseline, all proxies were asked to select which level of care they felt the resident should receive: intensive, basic, or comfort care. Multivariable logistic regression identified resident and proxy factors associated with a preference for comfort care (vs. basic or intensive medical care). Results Proxy level of care preferences were: comfort, 62.2%; basic, 31.1%; and intensive medical care, 6.5%. In multivariable analyses, proxy perception that the resident had less than six months to live was most strongly associated with a preference for comfort-focused care (adjusted odds ratio 12.25, 95% CI 4.04–37.08). Additional factors significantly associated with a preference for comfort care included older resident age, worse resident cognitive impairment, and the proxy having been asked about goals of care preferences by a NH health care provider (adjusted odds ratio 1.71, 95% CI 1.07, 2.74). Conclusion Most proxies select comfort as the preferred level of care for NH residents with advanced dementia. Discussions regarding prognosis, as well as inquiry about goals of care, are modifiable factors that may promote a preference for comfort care in this population.

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Section: Discussionmentioning

confidence: 64%

Section: Discussionmentioning

confidence: 66%

“…2,4,9 Proxy refusal ( N = 672) was the only reason for non-participation. Non-participating and participating eligible residents did not differ with respect to age or gender.…”

Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Mitchell

Palmer

Volandes

et al. 2017

Journal of Pain and Symptom Management

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“…Similar work led by Laura Hanson, MD, MPH, integrated a goals-of-care decision aid and care plan meetings in nursing homes; the study demonstrated more treatment planning and fewer hospital transfers for residents with advanced dementia [18].…”

Section: Innovative Approaches To Ensure Value From Endof-life Care Cmentioning

confidence: 80%

Costs at the End of Life

Ernecoff

Stearns

2018

North Carolina Medical Journal

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Many elders require supportive services, with many costs covered by Medicaid. Once terminal illness sets in, palliative care and hospice may help control cost while ensuring quality. This commentary reviews trends in cost at the end of life and describes selected strategies to improve patient-centered care in North Carolina. L ife expectancy and medical innovation in the United States have increased dramatically over the last century [1]. The rise of antibiotics and critical care technologies (eg, ventilation, dialysis) allows people to live longer, with evidence indicating expansion rather than compression of morbidity between 1998 and 2008 [2]. This expansion of morbidity-as well as the increasing incidence of dementias at older ages and social trends around caregiving-challenges the ability of families to care for their aging elderly at home. The shift toward long-term care settings as elders approach the end of life is a driver of health care costs, making it an important societal conversation. While evidence indicates that hospitalizations decline with age [3], total costs remain high due to increasing incidence of chronic disease, declining functional status, and increasing use of longterm care services.The historical roots of health care reform in the United States yielded a Medicare system that does not cover longterm care costs, leaving those costs primarily to individual private pay or Medicaid. At the patient level, Medicare beneficiaries in need of long-term care must spend down certain assets to qualify for Medicaid, which will then kick in to cover long-term care costs. Long-term care can take diverse forms, including home care, nursing homes, and long-term acute care hospitals. In 2016, 21% of Medicaid costs in North Carolina (ie, $2.6 billion out of a total of Medicaid spending of $12.4 billion) were attributed to long-term care for younger, disabled individuals as well as the elderly, with community-based care accounting for 56% of long-term care costs [4].Compared to nursing home care, evidence suggests home-and community-based programs offer better quality of life, especially for patients with certain conditions, including dementia [5]. Various strategies target both costs and quality, including Home and Community-Based Service (HCBS) Waivers at the state level that act to support home-based care to keep people in their communities longer [6]. Innovations such as Continuing Care Retirement Communities (CCRCs) support independence and agingin-place, but they are primarily an option for persons with higher incomes who can buy into the model early. Longterm acute care facilities that support the chronically ventilated, critically ill-a smaller proportion of long-term care patients-present a different set of barriers to both cost and quality of life for residents, including protracted stays dependent on technology (eg, chronic ventilator support) that cannot be readily transferred to a community setting or even a less-equipped nursing home [7].Regardless of the location of long-term care, another ...

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Advance Directives for Dementia

Gaster

Larson

Curtis

2017

JAMA

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In the coming years, an increasing number of people will experience dementia. Worldwide, the number of people living with dementia is projected to increase from 47 million in 2015 to 132 million by 2050. 1 Family members and clinicians are often unsure whether the care they provide for such patients is the care that patients would have chosen. Across the care spectrum, including skilled nursing facilities, hospital wards, intensive care units, and outpatient clinics, family members and clinicians commonly encounter this dilemma.National campaigns have increased awareness of advance care planning to guide care for patients who can no longer make decisions for themselves. The Conversation Project, for example, has developed partnerships with more than 400 community organizations across the United States to provide tools to promote end-of-life conversations. 2 Advance directives, when incorporated into comprehensive goalsof-care discussions, are an important part of this planning and help reduce family anxiety about surrogate decision-making. 3 Standard advance directives are often not helpful for patients who develop dementia. Dementia is a unique disease from the standpoint of advance directives. It usually progresses slowly over many years and leaves people

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Effect of the Goals of Care Intervention for Advanced Dementia

Cited by 220 publications

References 35 publications

Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Costs at the End of Life

Advance Directives for Dementia

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