End-of-life care lacking in nursing homes
MedWire News: Staff in care homes need extra education and support to improve their delivery of end-of-life care to people with dementia, researchers believe.
The survey found that staff often used "opaque euphemisms" regarding death, were unaware of patients' advance care plans, and frequently misunderstood religious traditions.
"Interventions need to enable staff to communicate explicitly about care options and that someone with dementia is dying," suggest Gill Livingston (University College London, UK) and team writing in the International Journal of Geriatric Psychiatry.
The current study was part of ongoing research into advance planning for care home residents with dementia and their families. Qualitative methods were utilized, including questionnaires and structured interviews, to ascertain the opinions of nursing home staff on their ability to deliver end-of-life care to residents.
In all, 58 permanent staff in a 120-bed nursing home were interviewed for the study.
They cited four major factors as facilitating end-of-life care: staff expertise around end of life; staff having strong, caring relationships with residents; a wish for plans to be in place for residents; and respect for cultures and opinions.
Conversely, staff cited five main factors as barriers to them delivering end-of-life care: difficulties in communication; worries over blame; lack of support for staff; conflict between professional and private feelings; and lack of knowledge or beliefs in advanced decisions or power of attorneys.
Based on the interviews, Livingston and colleagues note that death remains a "largely taboo area," with staff showing particular difficulties when residents talked about their own impending death. Staff also found talking with relatives about dying "uncomfortable," and tended to avoid using words such as "death," instead focusing on appetite and mood.
Other staff viewed their role as being to preserve life for as long as possible, sending people to hospital, even against the family's expressed wishes. Fear of litigation drove a risk-averse approach by other staff.
Also, staff often gave "vague, contradictory answers" when asked about advanced directives and patients' decisions about care at the end of life.
"Some staff felt (incorrectly) that the lack of plans reflected the residents' cultural and religious choice," write Livingston et al. "The staff were concerned that advance plans would be invalidated and that relatives or residents would change their mind and blame them."
To overcome some of these barriers, the authors say it is "essential" that general practitioners, nurses, and care staff work more closely as a team and support each other.
"Within the team, care staff must know that they have the authority to implement advance care plans without blame and that management systems will protect and support them," they write.
"Additionally, a training program around care at the end of life should address not only knowledge about dementia and care at the end of life and completing advanced care plans but also staff attitudes, communication and interpersonal skills."
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By Joanna Lyford