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Source: Carpenter JG, Lam K, Ritter AZ, Ersek M. A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes. J Am Med Dir Assoc. 2020;21(5):583-596.e2. doi:10.1016/j.jamda.2019.11.015.
Background:
While it is known that palliative care has positive impacts on improving patient outcomes, appropriate use of healthcare resources and improved experiences of families and caregivers, much of the research has been done in settings other than nursing facilities. Almost 30% of older adults will receive care until death in a nursing home, yet do not receive treatment for their pain and other physical and non-physical symptoms. They may also receive treatments that are potentially burdensome and of limited benefit. In recent years there has been growth in nursing home palliative care programs. The intent of this study was to review new literature to examine the characteristics of interventions and their effectiveness.
Design and Participants:
This study was a systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. The authors searched MEDLINE, Embase, CINAHL, and Cochrane CENTRAL through January 1, 2019. Interventions were included if they included multiple interventions so that there was integration of more than one palliative care domain. There also needed to be a comparison, for example usual care, waitlist, historical control. Trials had to report on at least one of the following outcomes: healthcare use, symptoms, resident or family evaluation of the quality of care, advance care planning, quality of life, and costs/expenditures. Studies were evaluated for risk of bias.
Results:
After identifying 1167 records, 67 articles were selected for full text review. Following full text-review, 13 articles, published between 2004 and 2018 were retained. Of these, 7 were conducted in the United States. Regarding bias, 4 trials had high risk of bias and 5 had unclear risk of bias. Three major strategies were employed in the studies- advance care planning, staff education, integrating a palliative care team. Of them, staff education was the most common. The most common outcomes evaluated were healthcare use and symptoms.
Six studies identified improvement in the palliative care practices of the nursing home. Four identified increased involvement of physicians in the care of the residents in the last weeks of life and increased use of a pathway that assisted staff in providing end-of-life care. Two studies identified increased discussions regarding hospice with higher referral and enrollment. There were variable results regarding the use of acute care. In 5 studies, there was reduced use of emergency room visits, rehospitalizations, acute care admissions, days in acute care and death in hospital. However, 4 interventions did not yield an impact on emergency department use the last 3 months of life, rehospitalization or death in hospital. There were conflicting results on nursing home death. One study reported that the palliative care consult intervention resulted in patients being more likely to die in the nursing home, while another found that advance care planning was not associated with greater likelihood of dying in the nursing home or while receiving hospice services.
Regarding symptoms, most studies focused on measuring pain, respiratory issues, depressive symptoms and agitation. While 2 studies found an improvement in pain and symptom assessment and management processes, there was inconsistent evidence of enhanced patient symptom outcomes. Likewise, there were mixed results on effects of palliative care interventions on advance care planning and documentation with some studies showing increases in DNR orders and advance directives while others did not. There were inconsistent findings related to family satisfaction with end-of-life care. One study demonstrated a lower means cost per resident at three months prior to death and into the final month of life in the intervention group than a historical control group.
Commentary:
While there was enhancement of nursing home palliative care processes, increased hospice referrals and better documentation of pain and symptom assessment and management in six studies, most trials demonstrated either mixed or insufficient evidence regarding the effect of palliative care interventions on reduction of care that was potentially burdensome, symptom ratings, advance care planning discussion/documentation and improving family members’ evaluation of the care. There were 3 studies that included only residents with dementia and none of them found that palliative care interventions improved surrogate-reported pain. It is known that pain in this population is frequently unrecognized and underreported in long-term care.
There were 11 studies that used an intervention inclusive of palliative care education. The 4 trials that used only this approach had either mixed or no effect on resident symptoms. Of 7 studies using education in combination with one other strategy, 4 of them enhanced palliative care practices in the nursing home. While important, education alone may be inadequate as an intervention and the trend is toward incorporating other strategies along with education. There were 3 trials that used a specialty palliative care consultation team, and they demonstrated a reduction in potentially burdensome care inclusive of emergency department visits and hospital transfers. It is possible that this is attributable to the specialty training of consultants. However, the size of the palliative care workforce is inadequate to meet the need.
Overall, this paper concluded that there is limited evidence that palliative care interventions improve nursing home end-of-life outcomes. Despite being a comprehensive search for evidence, there are limitations to consider. Risk of bias requires caution with interpretation of the results. The trials were heterogenous in their approaches and sample sizes were small. Some trials that may have shown effective interventions may have been excluded from the review. It is unclear in multi-component studies, which interventions worked and which did not. Additionally, there may have been problems related to the implementation of the intervention rather than the intervention itself.
Bottom Line:
There is limited evidence for multi-component nursing home palliative care interventions. There was a small group of trials demonstrating improved nursing home palliative care and improved symptom assessment and management, but effects on other outcomes is not well demonstrated. Future research will need to focus on supporting nursing home providers in their delivery of primary palliative care, along with collaboration with experts, and identification of residents who would benefit. Further work will be needed to identify which components of interventions are most impactful. Attention will also need to be given to staffing utilization and costs.
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