Interventions for improving palliative care for older people living in nursing care homes Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract Background

Residents of nursing care homes for older people are highly likely to die there, making these places where palliative care is needed.

Objectives

The primary objective was to determine effectiveness of multi‐component palliative care service delivery interventions for residents of care homes for older people. The secondary objective was to describe the range and quality of outcome measures.

Search methods

The grey literature and the following electronic databases were searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (all issue 1, 2010); MEDLINE, EMBASE, CINAHL, British Nursing Index, (1806 to February 2010), Science Citation Index Expanded & AMED (all to February 2010). Key journals were hand searched and a PubMed related articles link search was conducted on the final list of articles.

Selection criteria

We planned to include Randomised Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), controlled before‐and‐after studies and interrupted time series studies of multi‐component palliative care service delivery interventions for residents of care homes for older people. These usually include the assessment and management of physical, psychological and spiritual symptoms and advance care planning. We did not include individual components of palliative care, such as advance care planning.

Data collection and analysis

Two review authors independently assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Meta analysis was not conducted due to heterogeneity of studies. The analysis comprised a structured narrative synthesis. Outcomes for residents and process of care measures were reported separately.

Main results

Two RCTs and one controlled before‐and‐after study were included (735 participants). All were conducted in the USA and had several potential sources of bias. Few outcomes for residents were assessed. One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end‐stage dementia. Two studies reported group differences on some process measures. Both reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital in the intervention group, the other found an increase in do‐not‐resuscitate orders and documented advance care plan discussions.

Authors' conclusions

We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost‐effectiveness, and reducing bias.

Author(s)

Sue Hall, Anna Kolliakou, Hristina Petkova, Katherine Froggatt, Irene J Higginson

Abstract

Plain language summary

Improving palliative care for older people in care homes

People are living longer, however, the very old often have many health problems and disabilities which result in them living and eventually dying in care homes. Residents of such homes are highly likely to die there, making these places where palliative care is needed. Palliative care provides relief from pain and other distressing symptoms experienced by people reaching the end of life. Palliative care hopes to help people live as actively as possible until death, and their families cope with the illness and bereavement. The aim of this review was to see how effective palliative care interventions in care homes are, and to describe the outcome measures used in the studies. We found only three suitable studies (735 participants), all from the USA. There was little evidence that interventions to improve palliative care for older people in care homes improved outcomes for residents. One study found that palliative care increased bereaved family members' perceptions of the quality of care and another found lower discomfort for residents with dementia who were dying. There were problems with both of these findings. Two studies found that palliative care improved some of the ways in which care was given in the care home, however, we do not know if this resulted in better outcomes for residents. There is a need for more high quality research, particularly outside the USA.

Author(s)

Sue Hall, Anna Kolliakou, Hristina Petkova, Katherine Froggatt, Irene J Higginson

Reviewer's Conclusions

Authors' conclusions

Implications for practice

There clearly is a need for effective palliative care interventions in care homes for older people, and the core principles and practices of palliative care, such as advance care planning and symptom management, could benefit all residents, not just those at the end of life (Morrison 2009). Our review found potentially promising results for three interventions: assessing residents' suitability for specialist palliative care and making recommendations to their physicians, developing palliative care expertise in care homes and moving residents with end‐stage dementia to special units in the care home. However, without further evaluation, we cannot recommend the use of the interventions in clinical practice. There is an absence of a shared understanding in the literature of what a palliative care intervention for residents should look like. Some features of the interventions evaluated in this review are likely to be important, for example, relationships between care homes and specialist palliative care services who can provide specialist support for residents with complex needs. Specialist services can also provide training and advice to care home staff who could provide a general palliative approach to care which is appropriate for all residents, regardless of their diagnosis or prognosis. However, training is a necessary but not sufficient condition to improve the care of residents. Other components, such as the development of multidisciplinary teams, are also likely to be important. Such teams were included in two of the interventions and are a key aspect of a palliative approach to care (Australian Government 2004).

Implications for research

There are methodological and structural challenges to conducting research in palliative care (Kaasa 2006), and these may be greater in care homes (Hall 2009), which are often run by for‐profit organizations and have no tradition of taking part in research. However, this review shows that it is possible to conduct controlled studies in these settings, at least in the USA. There is a need for high quality studies to be carried out in other cultural and geographical settings. Future studies need to take into account contamination of the control group in individually randomised studies, or the intra cluster correlation if cluster randomisation is used, identify and control for potential confounders, and avoid multiple significance testing or correct the P‐values reported to reduce the possibility of Type 1 errors. It would be useful to look at the various components of these complex interventions and explore, if and how, each contributes to outcomes. It is important to demonstrate that interventions are beneficial to residents. A core outcome measure covering the key goals of palliative care in nursing homes is needed, so that the results of future studies can be combined and compared. This needs to be short and easy to complete by residents or their proxies. It is important to report cost data so that the cost‐effectiveness of different interventions could be explored in future reviews. Many of the issues raised in this review, for example: the need to develop and test high quality measures and determine the clinical significance of interventions, have been raised in relation to wider research literature on end of life care (Lorenz 2004).

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