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ispartof: Journal of Hospital and Healthcare Administration vol:6 issue:172 status: published

Additional file 4: Fig. S2. a Time from ICU admission until at least 2 PECs during ICU stay (unweighted). b Time from ICU admission until death (unweighted). C Time from ICU admission until TLD during ICU stay (unweighted). TLD: treatment limitation decision, PEC: Perceptions of Excessive Care.

Additional file 2. Master dissertation of E. Uyttersprot.

Context Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. Objectives To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. Methods A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. Results We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). Conclusion Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

Additional file 5: Table S3. Mortality and TLDs across subgroups (unweighted results)

Additional file 1. Definitions of collected data.

Additional file 3: Fig. S1. Flowchart study unweighted results: number of ICU’s, clinicians, perceptions and patients. PEC: Perceptions of Excessive Care. Combined endpoint: death, poor quality of life or not being at home.

Additional file 4 : E-Table 4. Lawton instrumental Activities of Daily Living (iADL).

Background The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the ‘PACE Steps to Success’ intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries. Methods A cluster RCT was conducted. LTCFs were randomly assigned to intervention or usual care. LTCFs reported deaths of residents, about whom questionnaires were filled in retrospectively about resource use and quality of the last month of life. A health care perspective was adopted. Direct medical costs, QALYs based on the EQ-5D-5L and costs per quality increase measured with the QOD-LTC were outcome measures. Results Although outcomes on the EQ-5D-5L remained the same, a significant increase on the QOD-LTC (3.19 points, p value 0.00) and significant cost-savings were achieved in the intervention group (€983.28, p value 0.020). The cost reduction mainly resulted from decreased hospitalization-related costs (€919.51, p value 0.018). Conclusions Costs decreased and QoL was retained due to the PACE Steps to Success intervention. Significant cost savings and improvement in quality of end of life (care) as measured with the QOD-LTC were achieved. A clinically relevant difference of almost 3 nights shorter hospitalizations in favour of the intervention group was found. This indicates that timely palliative care in the LTCF setting can prevent lengthy hospitalizations while retaining QoL. In line with earlier findings, we conclude that integrating general palliative care into daily routine in LTCFs can be cost-effective. Trial registration ISRCTN14741671.

Additional file 2 : E-Table 2. Geriatric Risk Profile (GRP) a modified and translated version of the Triage Risk Screening Tool (TRST).

Additional file 3 : E-Table 3. Katz Activities of Daily Living (ADL): Evaluation scale for functional independence.

Additional file 1 : E-Table 1. Nutritional risk screening (NRS).

Additional file 7 : E-Table 7. non-respons bias: Basic descriptive statistics of participants with and without gait speed expressed as number (%) and median (range).

Additional file 6 : E-Table 6. Charlson Age-Comorbidity Index.

Additional file 5 : E-Table 5. Mini Mental State Examination (MMSE).

OBJECTIVES: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out‐of‐hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN: Subanalysis of an international multicenter cross‐sectional survey (REAPPROPRIATE). SETTING: Out‐of‐hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the “appropriate” subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the “uncertain” subgroup, and 2 of 107 (1.9%) in the “inappropriate” subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non‐shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non‐shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39–45, 2019

Background The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar. Methods The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support. Results Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1–3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention. Conclusions There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.

ACHTERGROND: Vroegtijdige zorgplanning (VZP) is een proces van reflectie en dialoog tussen de patiënt, zijn naasten en één of meerdere zorgverleners (waaronder een arts) waarbij toekomstige zorgdoelen besproken en gepland worden. Deze zorgdoelen zijn gebaseerd op wat de patiënt waardeert als kwaliteitsvolle zorg en ze kunnen steeds aangepast worden aan de veranderende situatie van de patiënt. Ze kunnen richting geven aan de beslissingen omtrent de zorg aan het levenseinde op het ogenblik dat de patiënt niet meer in staat is zijn wil te uiten. DOELSTELLING: Deze richtlijn formuleert adviezen over de praktische toepassing en het verloop van VZP bij de wilsbekwame volwassen patiënt (in het bijzonder ouderen, kankerpatiënten en patiënten met een chronische of progressieve levensbedreigende aandoening), zowel in de thuiszorg, het woonzorgcentrum (WZC) als het ziekenhuis. Vertrekkend vanuit de literatuur, wil deze richtlijn in de eerste plaats bruikbaar zijn voor artsen en verpleegkundigen. METHODE: Volgens het Algemeen Stramien Voor De Ontwikkeling Van Aanbevelingen Van Goede Medische Praktijkvoering werden in drie literatuurrondes 1) richtlijnen 2) systematic reviews en meta-analyses en 3) primaire studies geïnventariseerd, geselecteerd en beoordeeld naar kwaliteit. Voor het opstellen van de aanbevelingen werd de ADAPTE-procedure gebruikt. De bewijskracht en het niveau van evidentie werden uitgedrukt volgens het GRADE-systeem. RESULTATEN: Er werden 3 internationale richtlijnen over VZP geselecteerd. Aanvullend werden 7 systematic reviews en 17 primaire studies (waarvan 10 randomized controlled trails) geïncludeerd. De publicatiedata van deze artikelen bestrijken de periode van januari 1999 tot en met maart 2011. Vroegtijdige zorgplanning wordt daarin omschreven als communicatieproces tussen de patiënt, zijn naasten en één of meerdere zorgverleners (waaronder een arts) over toekomstige zorgdoelen. Het dient, met respect voor de waarden en voorkeuren van de patiënt, richting te geven aan de beslissingen omtrent de zorg aan het levenseinde op het ogenblik dat de patiënt niet meer in staat is zijn wil uiten. Zorgverleners nemen best zelf het initiatief om VZP ter sprake te brengen naar aanleiding van verschillende sleutelmomenten. [GRADE 1B-C] VZP-gesprekken dienen nauwkeurig te worden voorbereid en vinden best plaats in een rustige omgeving. [GRADE 1C] Het VZP-proces verloopt gefaseerd, afgestemd op de behoefte van de patiënt en zijn naaste(n). [GRADE 1C] VZP-gesprekken kunnen de tevredenheid over de geleverde zorg verbeteren en hebben zelden negatieve invloed op stress, angst en depressie bij patiënten en familieleden. [GRADE 1A] VZP kan de nauwkeurigheid verbeteren waarmee de vertegenwoordiger de wensen van de patiënt inschat. [GRADE 1A] Patiënten goed informeren (gecombineerd schriftelijk en mondeling) over VZP resulteert in een toename van de documentatie van zorgvoorkeuren in het medisch dossier. [GRADE 1A] Het vroegtijdig starten van palliatieve zorg met speciale aandacht voor zorgplanning kan het aantal levensverlengende behandelingen aan het levenseinde verminderen. [GRADE 1A] Patiënten en naasten worden best herhaaldelijk gesensibiliseerd en geïnformeerd volgens hun behoefte. [GRADE 1A] Zorgverleners dienen opgeleid te worden met betrekking tot de verschillende deeltaken in het proces van VZP. [GRADE 1A-C] Zorgverleners stellen best schriftelijke informatie ter beschikking aan hun patiënten ter ondersteuning van een VZP-gesprek. [GRADE 1A] Documenten en formulieren worden best in een eenvoudige en duidelijke taal opgesteld. [GRADE 1A] BESLUITEN: VZP is een communicatieproces tussen een patiënt, diens naasten en één of meerdere zorgverleners (waaronder een arts) dat gefaseerd verloopt naargelang de behoeften van de patiënt en zijn naaste(n) en dat tot doel heeft, met respect voor de waarden en voorkeuren van de patiënt, richting te geven aan de beslissingen omtrent de zorg aan het levenseinde (in het bijzonder op het ogenblik dat de patiënt niet meer in staat is zijn wil te uiten). VZP-gesprekken kunnen de tevredenheid over de geleverde zorg verbeteren en hebben zelden een negatieve invloed op stress, angst en depressie bij patiënten en familieleden. Zorgverleners dienen opgeleid te worden met betrekking tot de verschillende deeltaken in het proces van VZP. status: published

status: published