Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Abstract

Purpose Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death. Patients and Methods A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal. Results Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death. Conclusion This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

Factors associated with dietitian referrals to support long‐term care residents advancing towards the end of life

“…This study is part of a larger study intended to understand the nutrition care experience for LTC residents in the last 6 months of life, which has already established that eating challenges increase in severity and complexity with proximity to death. 26 Apart from routine assessments, dietitian involvement for new or worsening eating challenges among residents is often contingent on referrals from a multidisciplinary team of care providers, most often nursing staff. 1,27 However, the circumstances around such referrals (e.g., frequency, reasons for referral, resulting interventions) as they relate to the end-of-life decline of residents in current practice are unclear.…”