Background: end-of-life care is not always in line with end-of-life preferences, so patients do not always die at their preferred place of death (PPD). This study aims to identify factors associated with patients' PPD and changes in PPD. Methods: we prospectively collected data on PPD at four time points within 6 months from 230 acutely hospitalised older patients who were part of the control group in a stepped-wedge randomised controlled trial. Associations between patient characteristics and preferences were calculated using multivariable (multinomial) logistic regression analysis. Results: the mean age of participants was 80.7 years. 47.8% of the patients had no PPD at hospital admission. Patients previously admitted to hospital preferred to die at home (home versus no preference: odds ratio [OR] 2.38, 95% confidence interval [CI] 1.15-4.92; home versus healthcare facility: OR 3.25, 95% CI 1.15-9.16). Patients with more chronic diseases preferred the healthcare facility as their PPD (healthcare facility versus no preference: OR 1.33, 95% CI 1.09-1.61; healthcare facility versus home: OR 1.21, 95% CI 1.00-1.47). 32 of 65 patients changed their preference during follow-up, and most of these had no PPD at hospital admission (home versus no preference: OR 0.005, 95% CI ≤0.001-0.095) and poorer self-rated well-being (OR 1.82, 95% CI 1.07-3.08). Conclusions: almost half of the patients had no PPD at baseline. Previous hospital admission, having more chronic diseases and living alone are associated with having a PPD. Introducing PPD could make older people aware of PPD and facilitate optimal palliative care.
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Background: Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. Aim: To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. Design: Systematic review and meta-analysis. Data sources: MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. Results: About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34–0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07–0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26–3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23–18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. Conclusion: Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.
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Referral to home-based cardiac rehabilitation (HBCR) is low among older and frailer patients due to low expectations regarding adherence by healthcare professionals. The aim of this study was to determine adherence to HBCR when old and frail patients are referred, and to explore any differences in baseline characteristics between adherent and nonadherent patients. Data of the Cardiac Care Bridge were used (Dutch trial register NTR6316). The study included hospitalized cardiac patients ≥ 70 years old and at high risk of functional loss. Adherence to HBCR was confirmed when two-thirds of the intended nine sessions were followed. Of the 153 patients included (age: 82 ± 6 years, 54% female), 29% could not be referred due to death before referral, not returning home, or practical problems. Of the 109 patients who were referred, 67% adhered. Characteristics associated with non-adherence were older age (84 ± 6 vs. 82 ± 6, p = 0.05) and higher handgrip strength in men (33 ± 8 vs. 25 ± 11, p = 0.01). There was no difference in comorbidity, symptoms, or physical capacity. Based on these observations, most older cardiac patients who return home after hospital admission appear to adhere to HBCR after referral, suggesting that most older cardiac patients are motivated and capable of receiving HBCR.
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Background: The number of medical technologies used in home settings has increased substantially over the last 10-15 years. In order to manage their use and to guarantee quality and safety, data on usage trends and practical experiences are important. This paper presents a literature review on types, trends and experiences with the use of advanced medical technologies at home. Methods: The study focused on advanced medical technologies that are part of the technical nursing process and 'hands on' processes by nurses, excluding information technology such as domotica. The systematic review of literature was performed by searching the databases MEDLINE, Scopus and Cinahl. We included papers from 2000 to 2015 and selected articles containing empirical material. Results: The review identified 87 relevant articles, 62% was published in the period 2011-2015. Of the included studies, 45% considered devices for respiratory support, 39% devices for dialysis and 29% devices for oxygen therapy. Most research has been conducted on the topic 'user experiences' (36%), mainly regarding patients or informal caregivers. Results show that nurses have a key role in supporting patients and family caregivers in the process of homecare with advanced medical technologies and in providing information for, and as a member of multi-disciplinary teams. However, relatively low numbers of articles were found studying nurses perspective. Conclusions: Research on medical technologies used at home has increased considerably until 2015. Much is already known on topics, such as user experiences; safety, risks, incidents and complications; and design and technological development. We also identified a lack of research exploring the views of nurses with regard to medical technologies for homecare, such as user experiences of nurses with different technologies, training, instruction and education of nurses and human factors by nurses in risk management and patient safety.
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The carbon sink capacity of tropical forests is substantially affected by tree mortality. However, the main drivers of tropical tree death remain largely unknown. Here we present a pan-Amazonian assessment of how and why trees die, analysing over 120,000 trees representing > 3800 species from 189 long-term RAINFOR forest plots. While tree mortality rates vary greatly Amazon-wide, on average trees are as likely to die standing as they are broken or uprooted—modes of death with different ecological consequences. Species-level growth rate is the single most important predictor of tree death in Amazonia, with faster growing species being at higher risk. Within species, however, the slowest-growing trees are at greatest risk while the effect of tree size varies across the basin. In the driest Amazonian region species-level bioclimatic distributional patterns also predict the risk of death, suggesting that these forests are experiencing climatic conditions beyond their adaptative limits.These results provide not only a holistic pan-Amazonian picture of tree death but largescale evidence for the overarching importance of the growth–survival trade-off in driving tropical tree mortality.
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Background: Although the number of older patients requiring medical care is increasing, caring for older patients is often seen as unattractive by medical trainees (i.e., medical students, residents, interns, and fellows). Terror Management Theory states that people have a negative attitude towards older people, because they remind people of their own mortality. We hypothesize that ageism, death anxiety, and ageing anxiety among medical trainees negatively affect their attitude towards medical care for older patients. This review aimed to examine and generate an overview of available literature on the relationship between ageism, death anxiety, and ageing anxiety among medical trainees and their attitude towards medical care for older patients. Methods: A systematic review was performed with a review protocol based on the PRISMA Statement. PubMed, Ebsco/PsycInfo, Ebsco/ERIC and Embase were searched from inception to August 2022, using the following search terms, including their synonyms and closely related words: “medical trainees” AND “ageism” OR “death anxiety” OR “ageing anxiety” AND “(attitude AND older patient)”. Results: The search yielded 4072 different studies; 12 eligible studies (10 quantitative and 2 qualitative) were identified and synthesized using narrative synthesis. Findings suggest that a positive attitude towards older people was related to a positive attitude towards medical care for older patients among medical students. The available literature on the relationship between death anxiety and/or ageing anxiety and attitude towards medical care for older patients among medical trainees was limited and had a heterogeneity in focus, which hindered comparison of results. Conclusion: Our findings suggest that a positive attitude towards older people in general is related to a positive attitude towards medical care for older patients among medical students. Future research should focus on further exploring underlying mechanisms affecting the attitude towards medical care for older patients among medical trainees.
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Abstract The aim of this cross-sectional study was to develop a Frailty at Risk Scale (FARS) incorporating ten well-known determinants of frailty: age, sex, marital status, ethnicity, education, income, lifestyle, multimorbidity, life events, and home living environment. In addition, a second aim was to develop an online calculator that can easily support healthcare professionals in determining the risk of frailty among community-dwelling older people. The FARS was developed using data of 373 people aged ≥ 75 years. The Tilburg Frailty Indicator (TFI) was used for assessing frailty. Multivariate logistic regression analysis showed that the determinants multimorbidity, unhealthy lifestyle, and ethnicity (ethnic minority) were the most important predictors. The area under the curve (AUC) of the model was 0.811 (optimism 0.019, 95% bootstrap CI = −0.029; 0.064). The FARS is offered on a Web site, so that it can be easily used by healthcare professionals, allowing quick intervention in promoting quality of life among community-dwelling older people.
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BackgroundTo improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway.MethodsWe conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands.ResultsThe palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84–5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49–6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation.ConclusionsThe pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.
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Purpose: This study examined the effects of a giant (4×3 m) exercising board game intervention on ambulatory physical activity (PA) and a broader array of physical and psychological outcomes among nursing home residents. Materials and methods: A quasi-experimental longitudinal study was carried out in two comparable nursing homes. Ten participants (aged 82.5±6.3 and comprising 6 women) meeting the inclusion criteria took part in the 1-month intervention in one nursing home, whereas 11 participants (aged 89.9±3.1 with 8 women) were assigned to the control group in the other nursing home. The giant exercising board game required participants to per-form strength, flexibility, balance and endurance activities. The assistance provided by an exercising specialist decreased gradually during the intervention in an autonomy-oriented approach based on the self-determination theory. The following were assessed at baseline, after the intervention and after a follow-up period of 3 months: PA (steps/day and energy expenditure/day with ActiGraph), cognitive status (mini mental state examination), quality of life (EuroQol 5-dimensions), motivation for PA (Behavioral Regulation in Exercise Questionnaire-2), gait and balance (Tinetti and Short Physical Performance Battery), functional mobility (timed up and go), and the muscular isometric strength of the lower limb muscles. Results and conclusion: In the intervention group, PA increased from 2,921 steps/day at baseline to 3,358 steps/day after the intervention (+14.9%, P=0.04) and 4,083 steps/day (+39.8%, P=0.03) after 3 months. Energy expenditure/day also increased after the intervention (+110 kcal/day, +6.3%, P=0.01) and after 3 months (+219 kcal/day, +12.3%, P=0.02). Quality of life (P<0.05), balance and gait (P<0.05), and strength of the ankle (P<0.05) were also improved after 3 months. Such improvements were not observed in the control group. The preliminary results are promising but further investigation is required to confirm and evaluate the long-term effectiveness of PA interventions in nursing homes.
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BACKGROUND: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation.METHODS: In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden.DISCUSSION: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.TRIAL REGISTRATION: NTR6316 . Date of registration: April 6, 2017.
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