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M Canavan,D O'Neill
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Healthcare does not follow a linear track of prevention, health gain, health maintenance and palliative care. Instead, aspects of each occur to differing degrees at various stages of life1. While the palliative care component increases as we near the end of our life span, we also engage in a range of preventive measures in later life (and in nursing homes) such as influenza vaccination, falls prevention programmes, and cardiovascular prevention. Finding the right equipoise between the various components is a complex task, and the emergent interest in end of life care for older people provides an opportunity for reflection on the global care needs of this population. This is a significant issue, as although at any one time less than 5% of older people are resident in nursing homes, 46% of older people will spend time in a nursing home before they die2. Those in nursing homes are the most frail group of older people3, and nursing homes are an increasingly common place for older people to die. Are there synergies for improving during-life and end of life care in nursing homes, and what skill sets do we need to develop to ensure person-centred care throughout the stay in nursing home?
The promotion of better standards of care in nursing homes has been a growing theme in the international literature, and has been the catalyst for major initiatives such as the Minimum Data Set (a standardized needs assessment) in the USA and other countries4. At the heart of solving the challenge of high quality nursing home care is the provision of adequate numbers of adequately trained staff, with adequate support structures. The recent interest in palliative care for older people in Ireland serves as a prompt to see where this initiative might fit into, and support, the wider care spectrum of needs of older people. Navigating the juncture when really sick becomes dying is particularly challenging, and is a core part of gerontologically-attuned health care, whether geriatric medicine or gerontological nursing. Is it possible that improving during life care will improve end of life palliative care?5 Although a range of professionals provide care for older people in nursing homes, the two largest professional groups are nurses and family doctors. At least three sets of training skills are relevant to these professions in nursing home care: gerontology, dementia care and palliative care. Gerontological nursing promotes both during-life and end of life care for older people in nursing homes: the specialist knowledge, skills and attitudes facilitate the understanding and ability to deal with the complex issues of ageing, disability, rehabilitation, communication and palliation. Although this type of training of care staff in nursing homes can greatly improve quality of life for older patients6, it is under-represented currently in nearly all settings of care for older people.
Official recognition has been tardy and has failed to adequately recognize the specialist skills needed for the complex care of older people. A document released by An Bord Altranais in 2009 on nursing older people failed to mention gerontological nursing or specialist nursing of older people, an omission highlighted by a similar document in the UK released two months previously which specified that nursing older people was a specialism7,8. Similarly, a review of end of life care in Irish nursing homes catalogued various technical and professional capacities, but not whether the nursing staff had any training in gerontological nursing9. Even the Health Information and Quality Authority (HIQA) standards for nursing homes (excellent in general) only specify gerontological training for directors of nursing10. For dementia care, specialist skills have been revolutionized by the pioneering work of Kitwood11. In recognising that the experience of dementia is unique to the individual and dependent on the interaction of many factors a person centred approach can be developed when considering care (including palliative elements) in this group. Dementia follows a disease trajectory that is progressive, individual and heterogeneous, and patients with dementia account for an increasing proportion of demand for palliative care, both in nursing homes and in the community.
Finally, the need for specific palliative care skills has become an emergent priority12. A formal focus on palliative care in nursing homes has been relatively recent and referral to hospice care for patients with dementia is very low. The majority of nursing home care staff in Ireland has not received any formal qualifications in palliative care. Less than one third of all facilities reported that their nurses held a post-registration qualification in palliative care or that their care/support staff had attended short courses in end-of-life care: it is of some relevance that we do not know the corresponding figures for gerontological or dementia care training9. Since 1994 there have been several reports on the reform of policy for palliative care services but many of the recommendations from these earlier reports have not been implemented and the focus remains on palliative care for cancer patients with little emphasis on older people, especially older people in long stay settings13. The value of educational interventions in palliative care can be considerable. A WHO Palliative Care Demonstration Project providing basic training in palliative care for all healthcare professionals increased access to specialist care in palliative care for long term, non-cancer, chronic conditions and saved an estimated eight million euro on acute hospital services and resources14,15.
Strategically, the Irish health services, and in particular nurses and general practitioners need to consider the best approach to developing a synthesis of gerontological, palliative and dementia expertise in the nursing home and community setting which will enhance care of this patient group in conjunction with specialist nurses, physicians, psychiatrists and allied health professions. A gerontologically attuned approach to care is central as ageing and disability affect virtually all nursing home residents, while dementia and death are common but not universal. A synthesis of these skill sets is essential as expertise in one particular area is not sufficient in isolation. We do not yet know the right combination, and a recent study on end of life care of those with advanced dementia in nursing homes omitted to factor in the skill bases of the attending nurses and doctors16. Further studies need to factor in the three skill sets in order for us to appraise how we care for people with age-related disease and disability, and in particular dementia, at the end of their lives. It would be prudent to address the gap in the education of our nurses and doctors in relation to gerontological, dementia and palliative skills so that these specialist skills can be developed from an early stage in training. If a drive for better palliative care for older people also improves gerontological and dementia care, could it be that: "In my end is my beginning"?
M Canavan, D O’Neill
Centre for Ageing, Neurosciences and the Humanities, Adelaide and Meath Hospital, Tallaght, Dublin 24
Email doneill@tcd.ie
References
1. Lynn J, Adamson DM. Living well at the end of life: adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003
2. Spillman BC, Lubitz J. New estimates of lifetime nursing home use: have patterns of use changed? Med Care. 2002; 40:965-75.
3. Faulkner M, O’Neill D. Falconer M, O’Neill D. Profiling disability within nursing homes: a census-based approach. Age Ageing. 2007;36:209-13.
4. Bernabei R, Landi F, Onder G, Liperoti R, Gambassi G. Second and third generation assessment instruments: the birth of standardization in geriatric care. J Gerontol A Biol Sci Med Sci. 2008; 63:308-13.
5. Finucane TE. How gravely ill becomes dying: a key to end-of-life care. JAMA 1999; 282:1670
6. Arnetz JE, Hasson H. Evaluation of an educational "toolbox" for improving nursing staff competence and psychosocial work environment in elderly care:results of a prospective, non-randomized controlled intervention. Int J Nurs Stud 2007;44:723-35.
7. An Bord Altranais. Professional Guidance for Nurses working with Older People. An Bord Altranais, Dublin, 2009.
8. Nursing and Midwifery Council. Guidance for the care of older people. Nursing and Midwifery Council, London, 2009.
9. O'Shea E, Murphy K, Larkin P, Payne S, Froggatt K, Casey D, Ní Léime A, Keys M. End of life care for older peoplein acute and long stay care settings in Ireland. Hospice Friendly Hospitals Programme and National Council on Ageing and Older People, Dublin, 2008.
10. Health Information and Quality Authority. National Quality Standards for Residential Care Settings for Older People in Ireland. Health Information and Quality Authority, Cork, 2008
11. Kitwood T. Dementia Reconsidered: The person comes first. Milton Keynes, Open University Press, 1997.
12. Furman CD, Pirkle R, O'Brien JG, Miles T. Barriers to the implementation of palliative care in the nursing home. J Am Med Dir Assoc. 2006 Oct;7:506-9.
13. Volicer L. End-of-life care for people with dementia in residential care settings. Chicago, Alzheimer’s Association, 2005.
14. Gómez-Batiste X, Porta Sales J, Pascual A, Nabal M, Espinosa J, Paz S, Minguell C, Rodríguez D, Esperalba J, Stjernswärd J, Geli M; Palliative Care Advisory Committee of the Standing Advisory Committee for Socio – Health Affairs, Department of Health, Government of Catalonia.. Catalonia WHO Palliative Care Demonstration Project at 15 Years. Journal of Pain and Symptom Management 2005; 33: 584-590.
15. Gómez-Batiste X, Tuca A, Corrales E, Porta Sales J, Amor M, Espinosa J, Borràs JM, de la Mata I, Castellsagué X; Grupo de Evaluación-SECPAL. Resource consumption and costs of palliative care services in Spain: a multicenter prospective study. Journal of Pain and Symptom Management 2006;31: 522-32.
16. Mitchell SL, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, Volicer L, Givens JL, Hamel MB. The Clinical Course of Advanced Dementia. N Engl J Med 2009; 361:1529-38.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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