Regional Workshops to Disseminate Decision Guide to Reduce Potentially Preventable Hospital Transfers: Application of the Diffusion of Innovation Model.

INTRODUCTION: Medically unnecessary, potentially preventable transfers of nursing home (NH) residents to acute care poses multiple risks for residents. Family and resident insistence on these preventable transfers has not been thoroughly addressed in transfer reduction programs. METHODS: The Diffusion of Innovation model guided dissemination of an evidence-based patient decision guide that addressed resident and family insistence on hospital transfer. Twenty workshops were held across eight states of Centers for Medicare and Medicaid Services Region IV. All Medicare-certified NHs in Region IV received emailed invitations to the workshops in their states. Quantitative and qualitative data were collected on workshop attendees, the facilities they represented, and response to the workshop including adoption of the Guide and its effect on hospital readmissions. RESULTS: Altogether, 1124 facility representatives and affiliated professionals attended the workshops. NH administrators rated the program 4.4 out of 5. Of those who responded, 71% said that they were using the Guide as a result of the workshop; 89% of these said that it was helpful, especially to initiate difficult conversations about end-of-life care and to discuss the care a contemporary NH can provide. Readmission rates dropped 30% in the NHs that reported their results. CONCLUSIONS: The use of the Diffusion of Innovation model was effective in delivering information to a large number of facilities in sufficient detail to implement the Decision Guide. However, the workshop format provided little opportunity to respond to concerns that arose after the workshops, to diffuse the innovation further, or to build sustainability.

Nursing Home Resident, Family, and Staff Perspectives on Achieving Comfort at End of Life: A Qualitative Study.

Increasing numbers of US older adults die in long-term care facilities. This qualitative study explored nursing home resident, family member, and staff perspectives and preferences regarding end-of-life care for the resident. From 67 potential participants referred by staff, 47 were found eligible and consented, including 16 residents, 10 family members, and 20 staff. A semistructured questionnaire guided the interview process and included questions such as what matters most at the end of life and whether participants would opt for any of the 8 aggressive treatments proposed for a resident at the end of life. Data were analyzed using descriptive and pattern coding for thematic interpretation. The 3 themes that emerged were centrality of comfort, what matters most at the end of life, and promoting comfort. All participant groups overwhelmingly endorsed comfort as a priority. Some participants would accept aggressive treatment to alleviate suffering and promote comfort. Residents were concerned about the well-being of their families, whereas family members emphasized the importance of their presence and that their dying relatives were not suffering. Staff sometimes filled this role on their behalf. Ancillary staff emphasized bathing, dressing, and grooming the resident to preserve the resident's dignity. The results support comfort as a priority for care at the end of life and the need for more discussion to increase mutual agreement on goals of care and what promotes comfort for the resident and family.

Nursing Home Resident, Family, and Staff Perspectives on Hospital Transfers for End-of-Life Care.

Residents who are terminally ill often experience transfers to the emergency department resulting in hospitalizations, which may be potentially avoidable with treatment in the nursing home. This qualitative study explored the perspectives of 15 residents, 10 family members, and 20 nursing home staff regarding end-of-life care and the circumstances prompting resident transfers. Data analysis of participant interviews conducted January to May 2019 in a South Florida nursing home identified four themes related to transfer to the hospital: time left to live, when aggressive treatments would be unavailing, not knowing what the nursing home can do, and transfer decisions are situation-dependent. Study findings underscore the importance of increasing resident and family awareness of treatments available in the nursing home and person-centered advance care planning discussions. Further research should explore the reasons for residents' and family members' choice of aggressive therapies and their goals for care at the end of life.

Communicating With Nursing Home Residents About End of Life.

Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.

Helpful Approaches for Older Adults Living in a Retirement Community to Move Forward After the Death of a Significant Other.

The loss of a significant other often creates emotional distress for family members that can hamper the ability to meet everyday challenges and pursue wellness. The aim of this qualitative study was to understand the challenge of losing a significant other for older adult family members and the approaches identified as most helpful to promote their own well-being after this person dies. Story inquiry method guided the interview process with 15 older adult bereaved family members residing in a continuing care retirement community. Theory-guided content analysis was used for data analysis. Two themes described the challenges: uneasiness that permeates everyday living and precious memories and patterns of disconnect that breed discontent. Appreciating the rhythmic flow of everyday connecting and separating and embracing reality as situated in one's lifelong journey are the themes that encompass the helpful approaches used by participants. This study provided insights about the benefits of living in this community such as social networking and a possible drawback such as the frequency of death among residents. Future research should continue to investigate social service resources that older adults find most helpful after a significant other dies and the use of reminiscence groups as a form of bereavement support.

Challenges of older adults when a loved one was dying: Implications for nursing practice.

AIMS: To explore the challenge of losing a loved one who was hospitalized at end of life and identify approaches deemed most helpful by older adult family members to resolve this challenge. BACKGROUND: Nurses will be caring for a growing number of terminally ill older adults and their families. Research specific to older adults to address their needs when a loved one is dying is necessary to promote quality family-oriented care. METHODS: A qualitative descriptive exploratory study was conducted with a purposive sample of 15 older adult family members during July-August 2015. Methods for data collection and analysis included story theory inquiry and theory-guided content analysis. RESULTS: The dimensions of the challenge of losing a loved one include: moving from painful holding on to poignant letting go, uneasiness that permeates everyday living and precious memories, patterns of disconnect that breed discontent, and pervasive ambiguity that permeates perspectives about remaining time. Active engagement enabling exceptional care for loved ones, appreciating the rhythmic flow of everyday connecting and separating to get by, and embracing reality as situated in one's lifelong journey are the approaches to resolve this challenge. CONCLUSIONS: Knowing a loved one was well cared for through nurses' compassionate caring was most important to older adults. Further research to address the self-care strategies of older adults as a loved one is dying is necessary. This study's nursing implications has the potential to enhance the quality of family-oriented care at end of life in diverse healthcare settings.

Older Adults' Perspectives of End of Life After the Death of a Significant Other: A Secondary Analysis.

Many older adults have experienced the death of a significant other. Understanding their perspectives from this past experience may heighten nursing insights about the type of care they desire at the end of their lives. The aim of this secondary analysis was to describe how the death of a significant other influenced older adults' perspectives about their end of life. Fifteen older adults residing in a continuing care retirement community participated in the primary study that explored the challenge of losing a loved one. Inductive content analysis was used to derive 4 themes to explain their perspectives about end of life: peacefully slip away-no heroics, familiarity-making plans that stick, tying up loose ends-what's left to do, and accepting-my time is up. This study's findings imply that nurses, with medical providers, should openly discuss with older adults their end-of-life concerns and care desired. Clinicians should receive education such as the COMFORT conversation and End-of-Life Nursing Education Consortium courses. Further research should explore whether older adults may be more encouraged to formulate advance directives after the death of significant others and end-of-life issues in retirement communities. Increasing public awareness of palliative and hospice services is needed.

Remembering Pearl Harbor at 75 Years.

: On December 7, 1941, the Sunday-morning quiet of the U.S. naval base in Pearl Harbor, Hawaii, was shattered by dive-bombing Japanese fighter planes. The planes came in two waves-and when it was all over, more than 2,400 were killed and more than 1,100 were injured.Nurses were stationed at U.S. Naval Hospital Pearl Harbor, Tripler General Hospital (now Tripler Army Medical Center), Hickam Field Hospital, Schofield Barracks Station Hospital, and aboard the USS Solace, and witnessed the devastation. But they also did what nurses do in emergencies-they responded and provided care to those in need. Here are the stories of a few of those nurses.

Social, Economic, and Political Issues Affecting End-of-Life Care.

For many decades, Americans showed a preference for delaying death through a technological imperative that often created challenges for nurses in caring for dying patients and their families. Because of their vast knowledge of health and healing, and their proximity to patients' bedsides, nurses are often well positioned to advocate for healthcare reform and legislation to improve end-of-life care. This article provides an overview of the social, economic, and political factors that are shaping end-of-life care in the United States. First, historical perspectives on end-of-life care are presented to enhance understanding of why some clinicians and patients seem to resist change to current practices. Second, end of care issues related to advanced technology utilization, societal expectations of care, clinical practices, financial incentives, palliative care services, and policy reforms are discussed. Finally, future recommendations are provided to encourage nurses and other healthcare providers to improve care for individuals facing end-of-life care decisions.