Advance care planning in dementia: recommendations for healthcare professionals.

BACKGROUND: Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual's preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. METHODS: Following the Belgian Centre for Evidence-Based Medicine's procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). RESULTS: Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. CONCLUSION: No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.

The psychotropic education and knowledge test for nurses in nursing homes: striving for PEAK performance.

OBJECTIVES: The psychotropic education and knowledge test for nurses in acute geriatric care (PEAK-AC) measures knowledge of psychotropic indications, doses and adverse drug reactions in older inpatients. Given the low internal consistency and poor discrimination of certain items, this study aims to adapt the PEAK-AC, validate it in the nursing home setting and identify factors related to nurses' knowledge of psychotropics. METHOD: This study included nurses and nurse assistants employed by nursing homes (n = 13) and nursing students at educational institutions (n = 5) in Belgium. A Delphi technique was used to establish content validity, the known groups technique for construct validity (nrespondents = 550) and the test-retest procedure for reliability (nrespondents = 42). Internal consistency and item analysis were determined. RESULTS: The psychotropic education and knowledge test for nurses in nursing homes (PEAK-NH) (nitems = 19) demonstrated reliability (κ = 0.641) and internal consistency (Cronbach's α = 0.773). Significant differences between-group median scores were observed by function (p < 0.001), gender (p = 0.019), educational background (p < 0.001), work experience (p = 0.008) and continuing education (p < 0.001) for depression, delirium and pharmacotherapy topics. Items were acceptably difficult (nitems = 15) and well-functioning discriminators (nitems = 17). Median PEAK-NH score was 9/19 points (interquartile range 6-11 points). Respondents' own estimated knowledge was related to their PEAK-NH performance (p < 0.001). CONCLUSION: The PEAK-NH is a valid and reliable instrument to measure nurses' knowledge of psychotropics. These results suggest that nurses have limited knowledge of psychotropic use in nursing homes and are aware of their knowledge deficits. The PEAK-NH enables educational initiatives to be targeted and their impact on nurses' knowledge to be tracked.

Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube.

BACKGROUND: Blind placement of a nasogastric feeding tube is a common nursing procedure. Confirmation of the correct position in the stomach is warranted to avoid serious complications such as misplacement in the lung. Testing pH of aspirate from a tube is one of the techniques to confirm the tip position. The purpose of this study was to evaluate the auscultatory method and pH measurement with a pH cut-off point of 5.5 after tube insertion and to compare this with the 'gold standard': an abdominal X-ray. Also the feasibility of the pH method was evaluated. MATERIALS AND METHODS: Large prospective observational study in a general hospital. In adult hospitalised patients, the positioning of 331 feeding tubes was tested using two different methods to predict tube position in the stomach. RESULTS: In 98.9% (n=178) of aspirate samples with a pH ≤ 5.5, the tube was located in the stomach. If an aspirate could be obtained, the results of pH measurements showed a sensitivity of 78.4% and a specificity of 85.7%. Obtaining aspirate initially after placement was possible in approximately half of cases but after taking additional measures (including administration of air into the tube, side-positioning of the patient and re-aspiration after one hour) this increased to 81.6%. The sensitivity of the auscultatory method was 79% while the specificity was 61%. CONCLUSIONS: A pH of ≤ 5.5 from tube aspirate is adequate to check the position of the tube in the stomach. Additional measures improve the success to obtain an aspirate from the tube. The auscultatory method is unreliable.

End-of-life care of the geriatric patient and nurses' moral distress.

OBJECTIVES: Moral distress (MD) occurs when the health care provider feels certain of the ethical course of action but is constrained from taking that action. The purpose was to examine MD in geriatric nursing care and to identify factors related to MD. DESIGN: Cross-sectional survey. SETTING: Twenty nursing homes and 3 acute geriatric wards in Flanders (Belgium). PARTICIPANTS: Participants were 222 nurses providing geriatric care. MEASUREMENTS: Moral distress was assessed with an 18-item questionnaire, adapted from the Moral Distress Scale. Multivariate linear regression analysis was used to identify key factors (situational, work, and personal factors) related to MD. RESULTS: The response rate was 57%. The frequency score of MD was 1.1 (mean, range 0-4) and the intensity score of MD was 2.3 (mean, range 0-4). Nurses identified situations involving unjustifiable life support (mean product score MPS 4.8), unnecessary tests and treatments (MPS 4.4), and working with incompetent colleagues (MPS 4.3) as causing the most MD. Responding to requests for euthanasia (MPS 0.8) and increasing morphine in an unconscious patient believed to hasten death (MPS 1.2) were least likely to cause MD. The total MD score (sum of the 18 product scores) was significantly higher in nurses with intentional or actual job-leave (mean difference = 15.1, t = -3.5, P = .001). After adjusting for demographic factors, the following factors were independently associated with elevated MD: working in an acute geriatric care setting (as compared with the chronic geriatric care setting), a lack of involvement in end-of-life decisions, a lack of ethical debate, and specific measures of burnout (emotional exhaustion and personal accomplishment). CONCLUSION: Providing futile and inadequate care contributes to moral distress more than euthanasia and believing to hasten an unconscious patient's death by increasing morphine in geriatric end-of-life care. Nurses' moral distress is related to situational and work characteristics as well as to burnout and job-leave.

Mealtime care on a geriatric- psychiatric ward from the perspective of the caregivers: a qualitative case study design.

This study aims to obtain insight into the care process surrounding mealtimes within a geriatric-psychiatric ward from the perspective of the caregivers. A qualitative study was carried out in accordance with the case study method. Data was generated by participant observation, semi-structured interviews, and focus groups. A mealtime turned out to be a much more complex event than it appears to be, looking at it superficially. The caregivers recognize the valuable therapeutic meaning of the mealtime. Nevertheless, they experience internal conflict when it comes to certain significant problem areas in their search for a balance between the functional-organizational approach and the patient-oriented approach.

Living with dementia from the perspective of older people: is it a positive story?

Dementia, even at an early stage, may pose problems and challenge one's quality of life. Having accurate knowledge of what one experiences when living with dementia is important for developing proactive care for individuals with dementia and their families. The aim of our Grounded Theory study was to explore what it means for elderly people to live with early-stage dementia. We interviewed 20 elderly people with probable mild dementia and their family members. Living with dementia was often presented as a positive narrative, one that told of only minor problems and which stressed abilities and contentment with life. Being valued, rather than losing one's cognition or identity was central in their experience. More in-depth analyses of participants' narratives revealed, however, that they were constantly balancing their feelings of value and worthlessness, struggling to remain someone of value. This struggle was prompted by threats posed by dementia and by the persons' interactions with others. Superficially, a positive narrative may be understood as a lack of awareness or as denial due to cognitive loss. Our findings suggest, however, that we should look beyond this superficial view and seek to understand the narrative as an expression of one's attempt to counterbalance devaluation.

Implementation of discharge management for geriatric patients at risk of readmission or institutionalization.

OBJECTIVE: To evaluate whether implementation of discharge management by trained social workers or nurses reduces hospital readmissions and institutionalizations of geriatric patients in a real-world setting. DESIGN: Quasi-experimental design. SETTING: Six general hospitals in Belgium. PARTICIPANTS: A representative sample of 824 patients, 355 of whom were assigned to the experimental group receiving comprehensive discharge management and 469 to the control group receiving usual care. Inclusion criteria were patients admitted to a geriatric, rehabilitation, or internal medicine ward, not residing in a nursing home, and showing risk of readmission or institutionalization on admission in the hospital. INTERVENTION: In-hospital discharge planning according to a case management protocol allowing for adjustment to participating hospitals' case mix and patients' and families' specific needs. MAIN OUTCOME MEASURES: Hospital readmission within 15 and 90 days post discharge; institutionalization at discharge and within 15 and 90 days post discharge. RESULTS: Discharge management resulted in fewer institutionalizations (n = 53; 14.9%) compared with usual care (n = 130; 23.7%) (adjusted odds ratio = 0.47; CI 95% = 0.31-0.70). Readmission rates between the intervention and usual care group were not significantly different. CONCLUSIONS: This implementation project showed that a discharge planning intervention can reduce institutionalization rates of elderly patients in real-life settings.

Living with early-stage dementia: a review of qualitative studies.

AIM: This paper presents a literature review whose aim was to provide better understanding of living with early-stage dementia. BACKGROUND: Even in the early stages, dementia may challenge quality of life. Research on early-stage dementia is mainly in the domain of biomedical aetiology and pathology, providing little understanding of what it means to live with dementia. Knowledge of the lived experience of having dementia is important in order to focus pro-active care towards enhancing quality of life. Qualitative research is fundamentally well suited to obtaining an insider's view of living with early-stage dementia. METHOD: We performed a meta-synthesis of qualitative research findings. We searched MEDLINE, CINAHL, and PsycINFO and reviewed the papers cited in the references of pertinent articles, the references cited in a recently published book on the subjective experience of dementia, one thesis, and the journal Dementia. Thirty-three pertinent articles were identified, representing 28 separate studies and 21 different research samples. Findings were coded, grouped, compared and integrated. FINDINGS: Living with dementia is described from the stage a person discovers the memory impairment, through the stage of being diagnosed with dementia, to that of the person's attempts to integrate the impairment into everyday life. Memory loss often threatens perceptions of security, autonomy and being a meaningful member of society. At early stages of memory loss, individuals use self-protecting and self-adjusting strategies to deal with perceived changes and threats. However, the memory impairment itself may make it difficult for an individual to deal with these changes, thereby causing frustration, uncertainty and fear. CONCLUSIONS: Our analysis supports the integration of proactive care into the diagnostic process, because even early-stage dementia may challenge quality of life. Moreover, this care should actively involve both the individual with dementia and their family so that both parties can adjust positively to living with dementia.

Complexity in caring for an ageing heart failure population: concomitant chronic conditions and age related impairments.

The complexity of caring for the ageing heart failure (HF) population is further complicated by concomitant chronic conditions (i.e., polypharmacy, depression), age related impairments (i.e., hearing, visual and cognitive impairments, impairments in activities of daily living (ADL/IADL), and other issues (e.g., health illiteracy, lack of social support). This paper provides an overview of these risk factors, outlines how they individually and in interplay endanger favourable outcome by putting patients at risk for poor self-management. Moreover, suggestions are made on how these issues could be addressed and integrated in heart failure management by applying gerontological care principles in caring for the ageing heart failure population.

Empirical ethics in action: lessons from two empirical studies in nursing ethics.

Despite the burgeoning of publications in nursing ethics, only more recently has empirical evidence on nursing ethics been published. How nursing ethics can be empirically studied as well as enriched by empirical data will be the focus of this paper. Two empirical studies will be briefly presented and their contribution to ethics discussed. The first one is a quantitative research project about nurses' ethical behavior in daily practice. Using an adapted version of Kohlberg's theory of moral development, this study tried to describe and explore nurses' responses to ethical dilemmas in daily nursing practice. The second study attempted to describe the specificity of residential palliative care. A qualitative approach was used to explore and describe the processes that take place on an inpatient palliative care unit, and the experiences of patients, relatives and palliative care team members. The analysis of the value of both research projects for ethics underlines the power of empirical understanding in the relationship between research and ethics. The need for integration of both qualitative and quantitative research methodologies is argued.