A review of the implementation and research strategies of advance care planning in nursing homes

Background Nursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers). Methods A systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations. Results Sixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives. Conclusion ACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders

Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers

Trygve Johannes Lereim Sævareid,1 Reidun Førde,1 Lisbeth Thoresen,1,2 Lillian Lillemoen,1 Reidar Pedersen11Centre for Medical Ethics, University of Oslo, Oslo, Norway; 2Department of Health Sciences, University of Oslo, Oslo, NorwayPurpose: Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance.Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP.Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources.Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.Keywords: qualitative, person-centered care, whole-system approach, implementation, cognitive impairmen

Implementing advance care planning in nursing homes – study protocol of a cluster-randomized clinical trial

Background Close to half of all deaths in Norway occur in nursing homes, which signals a need for good communication on end-of-life care. Advance care planning (ACP) is one means to that end, but in Norwegian nursing homes, ACP is not common. This paper describes the protocol of a project evaluating an ACP-intervention in Norwegian nursing homes. The aims of this research project were to promote the possibility for conversations about the end of life with patients and relatives; promote patient autonomy; create a better foundation for important decisions in the case of medical emergencies and at the end of life; and gain experiences in order to find out what characterizes good ACP and good implementation strategies. Methods/design This study was a mixed method study including a cluster-randomized clinical trial. Eight nursing home wards or “clusters” were pair-matched, and one ward from each pair was randomly selected for a 12-month intervention. The intervention consisted of implementing an ACP-guideline. Implementation strategies were training and supervision of project teams and staff in using the guideline, written information to patients and next of kin, and information meetings with nursing home staff. The project was evaluated using both quantitative and qualitative data, and both outcome and process evaluation. Quantitative data included patient chart reviews of ACP, diagnoses, patient preferences for decision-making and treatment, values and wishes that are more general, documented life-prolonging treatment and hospitalizations, and concordance between patient wishes and treatment. The primary outcome was documented ACP. Qualitative data included observations of conversations, interviews with patients, next of kin and health care personnel, logs from project coordinators and conversations, and transcripts from meetings with project teams in the intervention group. Discussion This project attempted to increase the quality and use of ACP in Norwegian nursing homes (NH). A mixed methods approach, inclusion of patients with dementia, attempts to involve, as many patients as possible, and a sustainable implementation plan adapted to real life in nursing homes were strengths of the project

Sampling and Analysis at the Vortec Vitrification Facility in Paducah, Kentucky. Semiannual report, November 1, 1996--March 31, 1997

The Vortec Cyclone Melting System (CMS) facility; to be located at the U.S. Department of Energy (DOE) Paducah Gaseous Diffusion Plant, is designed to treat soil contaminated with low levels of heavy metals and radioactive elements, as well as organic waste. The primary components of Vortec`s CMS are a counter rotating vortex (CRV) reactor and cyclone melter. In the CMS process, granular glass forming ingredients and other feedstocks are introduced into the CRV reactor where the intense CRV mixing allows the mixture to achieve a stable reaction and rapid heating of the feedstock materials. Organic contaminants in the feedstock are effectively oxidized, and the inert inorganic solids are melted. The University of North Dakota Energy {ampersand} Environmental Research Center (EERC) has been contacted to help in the development of sampling plans and to conduct the sampling at the facility. This document is written in a format that assumes that the EERC will perform the sampling activities and be in charge of sample chain of custody, but that another laboratory will perform required sample analyses