Practice of end-of-life care for patients with advanced dementia by hospital physicians and nurses: Comparison between medical and surgical wards

Abstract

Background Patients with advanced dementia are commonly hospitalized in acute care wards, yet there is limited data regarding the end-of-life (EOL) care delivered to this population. The aim of the study was to examine EOL care delivered to patients with advanced dementia hospitalized on acute wards as reported by physicians and nurses. Methods Participants were physicians and nurses from medical and surgical wards of two tertiary hospitals in Israel. Participants completed a self-report questionnaire evaluating EOL care experiences, knowledge, performance, assessment, communication, and perceived futile care regarding patients with dementia. Results The questionnaire was completed by 315 providers. There were 190 medical ward respondents and 125 from general surgical wards. Of them, 48.6% recognized dementia as a terminal disease, while 26.0% of the participants reported that they knew the end-of-life preferences for less than 10% of their patients. Among the providers, 53.3% reported that end-of-life ward discussions took place only when there was a life-threatening situation and 11.1%–16.5% never engaged in end-of-life communication regarding EOL patient’s preferences, appointing an attorney for the patient, disease trajectory or the essence of palliative care, with patients or their representatives. Only 17.1% reported “never” performing care they considered to be futile for patients with advanced dementia. Controlling for gender, age, role, position (senior/junior), and exposure to patients with advanced dementia, surgical ward respondents reported performing less EOL care than medical ward respondents in almost all aspects of palliative care. Conclusions Despite growing attention, a significant portion of staff in acute care wards do not report applying EOL care to patients with advanced dementia in clinical practice, especially surgical ward staff.

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

“…Indeed, the lack of acquaintance regarding the options for end-of-life care was found to be a barrier to effective discussions about end-of-life among internal medicine residents [ 52 ]. We have recently reported that health personnel in general hospitals report low rates of end of life discussions with family members of hospitalized patients with dementia [ 53 ]. Some investigators found that knowledge deficits were negatively correlated with perceived self-efficacy [ 54 , 55 ], and positively correlated with lack of confidence in making care decisions for patients with AD and concerns about their ability to provide quality end-of-life care [ 12 , 56 ].…”

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings

“…Alpha Cronbach values of the MSQ and the PMCS in this study were 0.87 and 0.93, respectively, similar to the previous reports among nurses in the literature ( 53–56 ) (see Supplemental Files 1a and 1b for the Hebrew version of the MSQ and PMCS tools, respectively). (4) The authors designed the fourth questionnaire to evaluate the treatment approach for persons with AD in emergency life-threatening situations ( 6 , 31 ). The treatment approach was measured by analyzing responses to a hypothetical scenario of a person with AD presenting with aspiration pneumonia and acute respiratory failure in an acute care hospital.…”

“…The sum of the scores of the chosen interventions was termed the “Treatment Approach Score” and ranged from −1 to 11 (see Supplemental file 2a for the Questionnaire and Supplemental file 2b for the Hebrew Version of this Questionnaire). The authors designed this questionnaire and reviewed it for content validity using a panel of six geriatricians working in acute care settings ( 6 ). The fifth questionnaire included 12 items that assess potential components related to the following three cognitive biases: representativeness, availability, and anchoring.…”

“…The fifth questionnaire included 12 items that assess potential components related to the following three cognitive biases: representativeness, availability, and anchoring. This questionnaire is part of a larger questionnaire that assessed practices and perceptions regarding PC for persons with AD ( 6 , 31 ). Participants were asked to rate their level of agreement with the various statements on a 5-point Likert scale.…”

“…Studies have investigated factors associated with this low level of PC delivery, including demographic and work-related characteristics of healthcare workers (HCWs), such as administrative regulations (financial reimbursement, access to PC, time constraints, staff shortage, and services integration and collaboration, education, knowledge, or communication skills) ( 4 , 5 ), and professional orientation (surgical vs. medical) ( 6 ). However, another potentially important component in deciding whether to provide PC is the process of clinical thinking or reasoning by the HCW when making a treatment decision, which is considered the core of healthcare practice ( 7 ).…”