Advance directives and physicians' orders in nursing home residents with dementia in Flanders, Belgium: prevalence and associated outcomes

Background: Advance care planning (ACP) is an important element of high-quality care in nursing homes, especially for residents having dementia who are often incompetent in decision-making toward the end of life. The aim of this study was describe the prevalence of documented ACP among nursing home residents with dementia in Flanders, Belgium, and associated clinical characteristics and outcomes. Methods: All 594 nursing homes in Flanders were asked to participate in a retrospective cross-sectional postmortem survey in 2006. Participating homes identified all residents who had died over the last two months. A structured questionnaire was mailed to the nurses closely involved in the deceased resident's care regarding the diagnosis of dementia and documented care planning, i.e. advance patient directives, authorization of a legal representative, and general practitioners' treatment orders (GP orders). Results: In 345 nursing homes (58% response rate), nurses identified 764 deceased residents with dementia of whom 62% had some type of documented care plan, i.e. advance patient directives in 3%, a legal representative in 8%, and GP orders in 59%. Multivariate logistic regression showed that the presence of GP orders was positively associated with receiving specialist palliative care in the nursing home (OR 3.10; CI, 2.07-4.65). Chances of dying in a hospital were lower if there was a GP order (OR 0.38; CI, 0.21-0.70). Conclusions: Whereas GP orders are relatively common among residents with dementia, advance patient directives and a legal representative are relatively uncommon. Nursing home residents receiving palliative care are more likely to have a GP order. GP orders may affect place of death

Hospitalizations of nursing home residents with dementia in the last month of life: Results from a nationwide survey

Background: Hospitalizations of nursing home residents with dementia may not be uncommon. However, evidence from epidemiological studies outside the United States and knowledge about the circumstances of hospitalizations are lacking. Aim: To examine the proportion of nursing home residents with dementia hospitalized in the last month of life and factors associated with hospitalization. Design: The design is stratified cluster sampling survey. Nurses retrospectively registered demographic and dementia-related information about deceased residents with dementia. This included information about hospitalizations, persons involved in hospitalization decisions and type and content of information transferred when hospitalized. Setting/participants: Nursing home residents dying with dementia in Belgium (Flanders) in 2010. Results: In the final month of life, 19.5% of nursing home residents dying with dementia (N = 198) were hospitalized, including 4.6% admitted to an intensive care unit. For 12.2% of residents dying with dementia, a do-not-hospitalize advance directive was present, for 57.0%, a do-not-hospitalize general physician-order. Residents without a do-not-hospitalize general physician-order were more likely of being hospitalized (adjusted odds ratio: 3.4; 95% confidence interval: 1.3-8.7). None of the hospitalizations occurred at the request of the resident; 37% were at the request of relatives; curative or life-prolonging treatments were the most frequent reasons given. Information about the resident's nursing care or medical treatment was transferred in almost all hospitalizations, information about wishes and preferences for future care in 19%. Conclusion: Hospitalization in Belgian nursing home residents with dementia in the last month of life was common. Documentation of do-not-hospitalize physician-orders in the resident's medical files may prevent hospitalizations

"Learning a way of thinking" - World Café on clinical reasoning in nursing and midwifery education and practice across five European Union countries

Clinical reasoning is a key attribute of nursing and midwifery professionals. As a part of the Erasmus plus project, we designed a study with the aim of exploring the understanding of clinical reasoning as a concept, experiences of teaching clinical reasoning and practices related to using clinical reasoning in nursing and midwifery. A qualitative study was carried out using the World Café method, involving 44 participants from five European countries. The participants represented diverse professional backgrounds, including nurses, midwives and lecturers. Our analytical approach was based on a thematic analysis. We categorized the data into three main categories, namely, “Spiral of thinking”, “The learning and teaching of a way of thinking” and “Clinical reasoning in real life”, all under an overarching theme, “Learning a way of thinking”. This study highlighted areas of learning and teaching which can be improved in current nursing and midwifery education. Furthermore, it identified barriers, facilitators and practices from five European countries which can be used in the further development of nursing and midwifery curricula and courses with the aim of enhancing clinical reasoning competence and ultimately improving patient care

Continuous deep sedation until death in nursing home residents with dementia: a case series

Objectives: To describe the characteristics of continuous deep sedation until death and the prior decision-making process of nursing home residents dying with dementia and to evaluate this practice according to features reflecting sedation guideline recommendations. Design: Epidemiological retrospective study completed using a case series analysis. Setting: Flemish nursing homes in 2010. Participants: From a representative sample of 69 nursing homes, all residents who had dementia and had been continuously and deeply sedated until death over a period of 3 months were selected. Measurements: Questionnaires to general practitioners (GPs), nurses, and relatives most involved in the care of the resident regarding the clinical characteristics of the resident, how sedation was decided upon and performed, quality of care, and dying. Advanced dementia was identified using the Global Deterioration and Cognitive Performance Scale. Whether this practice is in conformity with sedation guideline recommendations was also investigated. Results: Eleven of 117 deceased residents with dementia (9.4%, 95% confidence interval (CI)=4.0-14.8) and nine of 64 residents with advanced dementia (14.1%, 95% CI=5.3-22.8) were sedated. Two of the 11 sedated residents were not considered to be terminal. Sedation duration ranged from 1 to 8days. Two received artificial food and fluids during sedation. Five were partly or fully competent at admission and three in the last week. Four had expressed their wishes or had been involved in end-of-life decision-making; for eight residents, the GP discussed the resident's wishes with their relatives. Relatives reported that five of the residents had one or more symptoms while dying. Nurses of three residents reported that the dying process was a struggle. For two residents, sedation was effective. Conclusion: Continuous deep sedation until death for nursing home residents does not always guarantee a dying process free of symptoms and might be amenable to improvement

Quality of dying of nursing home residents with dementia as judged by relatives

Background: Providing good quality care for the growing number of patients with dementia is a major challenge. There is little international comparative research on how people with dementia die in nursing homes. We compared the relative's judgment on quality of care at the end of life and quality of dying of nursing home residents with dementia in Belgium and the Netherlands. Methods: This was a Belgian cross-sectional retrospective study (2010) combined with a prospective and retrospective study from the Netherlands (January 2007-July 2011). Relatives of deceased residents of 69 Belgian and 34 Dutch nursing homes were asked to complete questionnaires. We included 190 and 337 deceased nursing home residents with dementia in Belgium and the Netherlands, respectively. Results: Of all identified deceased nursing home residents with dementia, respectively 53.2% and 74.8% of their relatives in Belgium and the Netherlands responded. Comfort while dying (CAD-EOLD, range 14-42) was rated better for Dutch nursing home residents than for Belgian nursing homes residents (26.1 vs. 31.1, OR 4.5, CI 1.8-11.2). We found no differences between countries regarding Satisfaction With Care (SWC-EOLD, range 10-40, means 32.5 (the Netherlands) and 32.0 (Belgium)) or symptom frequency in the last month of life (SM-EOLD, range 0-45, means 26.4 (the Netherlands) and 27.2 (Belgium)). Conclusion: Although nursing home structures differ between Belgium and the Netherlands, the quality of care in the last month of life for residents with dementia is similar according to their relatives. However, Dutch residents experience less discomfort while dying. The results suggest room for improved symptom management in both countries and particularly in the dying phase in Belgium