Managed Death in a PACE: Pathways in Present and Advance Directives

Schamp, Richard O.; Tenkku, Leigh E.

doi:10.1016/j.jamda.2006.01.022

Cited by 29 publications

(37 citation statements)

References 25 publications

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“…Of all LTC settings for older adults, NHs have been the subject of most of the research about palliative and EOL care. While there is interest in applying palliative care principles in LTC community settings such as Programs for All-inclusive Care of the Elderly (PACE) [14][15][16] and assisted living facilities (ALFs), [17][18][19][20][21][22] to date there is relatively little published palliative care research in these settings. Thus, this paper focuses on palliative care research conducted in NHs.…”

Section: Introductionmentioning

confidence: 99%

Geriatric Palliative Care in Long-Term Care Settings with a Focus on Nursing Homes

Ersek

Carpenter

2013

Journal of Palliative Medicine

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Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.

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Section: Introductionmentioning

confidence: 99%

Geriatric Palliative Care in Long-Term Care Settings with a Focus on Nursing Homes

Ersek

Carpenter

2013

Journal of Palliative Medicine

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“…Over half (20/37) of the studies were conducted in the USA, 22,25,[28][29][30][31]39,41,42,45,[47][48][49][50][52][53][54][55][56][57] nine were conducted in the UK, 26,[32][33][34][35]37,40,43,44 two were conducted in Australia 23,24 and one study was conducted in each of Germany, 46 Belgium, 38 Switzerland, 51 the Netherlands, 16 Singapore 36 and Saudi Arabia. 27 …”

Section: Settingmentioning

confidence: 99%

“…Of the 37 studies, eight were randomised controlled trials, [22][23][24]30,45,54,55,57 27 were before-and-after studies 16,[25][26][27][28][29][31][32][33][34][35][36][37][38][39][40][41][42][43][44][48][49][50][51][52][53]56 and two were cluster controlled studies. 46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,…”

Section: Quality Of Evidencementioning

confidence: 99%

“…46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,57 and 23 were assessed as providing weak evidence. [25][26][27][28][31][32][33][34]39,[41][42][43][44][45][46][47][48][49][50][51][52][53]56 REVIEW OF PUBLISHED EVIDENCE NIHR Journals Library www.journalslibrary.nihr.ac.uk…”

Section: Quality Of Evidencementioning

confidence: 99%

“…The introduction of structured advanced care planning in the community moved preferences towards less invasive levels of care at life's end and increased compliance with participants' wishes and deaths at home (including DNACPR). 48 …”

Section: Review Of Published Evidencementioning

confidence: 99%

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Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

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BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Integrating palliative care with usual care of diabetic foot wounds

Dunning

2016

Diabetes Metabolism Res

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Palliative care is a philosophy and a system for deciding care and can be used alone or integrated with usual chronic disease care. Palliative care encompasses end-of-life care. Palliative care aims to enhance quality of life, optimize function and manage symptoms including early in the course of chronic diseases. The purposes of this article are to outline palliative care and discuss how it can be integrated with usual care of diabetic foot wounds. Many people with diabetes who have foot wounds also have other comorbidities and diabetes complications such as cardiovascular and renal disease and depression, which affect medicine and other treatment choices, functional status, surgical risk and quality of life. Two broad of diabetic foot disease exist: those likely to heal but who could still benefit from integrated palliative care such as managing pain and those where healing is unlikely where palliation can be the primary focus. People with diabetes can die suddenly, although the life course is usually long with periods of stable and unstable disease. Many health professionals are reluctant to discuss palliative care or suggest people to document their end-of-life care preferences. If such preferences are not documented, the person might not achieve their desired death or place of death and health professionals and families can be confronted with difficult decisions. Palliative care can be integrated with usual foot care and is associated with improved function, better quality of life and greater patient and family satisfaction.

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Managed Death in a PACE: Pathways in Present and Advance Directives

Cited by 29 publications

References 25 publications

Geriatric Palliative Care in Long-Term Care Settings with a Focus on Nursing Homes

Geriatric Palliative Care in Long-Term Care Settings with a Focus on Nursing Homes

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Integrating palliative care with usual care of diabetic foot wounds

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