Title:
Lack of Effect of a Multicomponent Palliative Care Program for Nursing Home Residents on Hospital Use in the Last Month of Life and on Place of Death: A Secondary Analysis of a Multi-country Cluster Randomized Control Trial
Background:
PACE, Palliative Care for Older people, is a European funded project. It compares the effectiveness of palliative care in nursing homes with a goal of providing advice to policy makers regarding best palliative care practices.
The PACE program is a six-step program including advance care planning, care planning and assessment, care coordination, high quality care that focuses on both pain and depression, care in the last days of life and after death care. It targeted the implementation of palliative care by non-specialists in nursing homes so that they could deliver high quality end of life care.
A cluster randomized controlled trial was done to evaluate its effectiveness with the primary outcome being resident comfort in the last week of life. While this was not affected, it was thought that there may be some effect on place of death and hospital use at the end of life, so a secondary analysis was done, which is the focus of this article.
Design and Participants:
A clustered randomized controlled trial was conducted. It involved 78 European nursing homes between 2015 and 2017. There was stratification by country and median number of nursing home beds. All nursing homes were categorized into two groups, which was determined based on the number of beds. Half were assigned as controls and the other half to the intervention arm, which was the PACE program.
Baseline data regarding patients dying in the preceding 4 months at participating facilities was collected. At months 13 and 17 post intervention, questionnaires were completed on residents who had died in the previous 4 months.
For this secondary analysis, the focus was on items that related to hospital utilization in the last month of life, hospital admissions and length of stay, ICU admissions and number of ICU nights, place of death, if death occurred in hospital and reason patient got admitted to hospital.
Results:
Per the article, 551 out of 610 questionnaires were collected from staff at baseline.
984 out of 1178 questionnaires were collected postintervention from 37 homes in the intervention arm and 36 homes in the control arm.
604 out of 613 questionnaires were collected from nursing home administrators at baseline.
1146 out of 1179 were collected from nursing home administrators at postintervention.
There were no statistically significant demographic differences between the residents and no significant differences between the control and intervention groups in terms of age, gender, cognitive and functional status.
There was no statistically significant effect of the PACE program on ED visits, hospital admissions, hospital length of stay in the last month of life or place of death. The shortened mean length of stay post intervention was not statistically significant.
Commentary:
This intervention did not have an effect on the primary outcome of resident comfort in the last week of life or the secondary outcomes of hospital use at the end of life and place of death. It may be that this type of broad-based program administered by non-palliative care specialists is insufficient to impact the outcomes measured. Additionally, there were no clinical guidelines to help determine how to manage the end-of-life symptoms. Management of acute symptoms or life-threatening situations were found to be main reasons for hospitalization. There was also no direction on when to get the primary provider involved. It may be that embedded specialist palliative care teams would have been helpful for the more challenging cases. More family involvement and education may also have been helpful.
Bottom Line:
This program wasn’t effective in achieving any defined outcomes. The nursing home environment is complex and future research may be indicated to determine if a multifaceted program in the nursing home environment, involving the residents, families, staff, primary provider, palliative care team, specifically focused on preventing end of life hospitalizations, may be more effective.
References:
Final Report Summary - PACE (Comparing the effectiveness of palliative care for elderly people in long term care facilities in Europe). Accessed September 25, 2023. https://cordis.europa.eu/project/id/603111/reporting
Source:
Honinx E, Smets T, Piers R, Pasman HRW, Payne SA, Szczerbińska K, Gambassi G, Kylänen M, Pautex S, Deliens L, Van den Block L. Lack of Effect of a Multicomponent Palliative Care Program for Nursing Home Residents on Hospital Use in the Last Month of Life and on Place of Death: A Secondary Analysis of a Multicountry Cluster Randomized Control Trial. J Am Med Dir Assoc. 2020 Dec;21(12):1973-1978.e2. doi: 10.1016/j.jamda.2020.05.003. Epub 2020 Jul 6. PMID: 32646823.
Reviewer:
Karen Sobers, MD
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