dementia living in a nursing home. That there is moderate level evidence that case conferencing improves the delivery of a palliative approach to care for people ...
1
International Journal of Nursing Studies
Review
Does case conferencing for people with advanced dementia living in nursing homes improve care outcomes: Evidence from an integrative review? Jane L. Phillips a,b,c,*, Penny A. West b, Patricia. M. Davidson d,e,c, Meera Agar c,f,g,h,i a
The University of Notre Dame Australia, School of Nursing, Sydney, Australia The Cunningham Centre for Palliative Care, Sacred Heart Hospice IMPACT: Improving Palliative Care Through Clinical Trials – NSW Palliative Care Clinical Trials Collaborative Group, Sydney, Australia d University of Technology Sydney, School of Nursing, Sydney, Australia e St Vincent’s Mater Health Sydney, Australia f Flinders University, Adelaide, Australia g HammondCare, Sydney, Australia h South West Sydney Clinical School, University of New South Wales, Sydney, Australia i South West Sydney Local Health Network Palliative Care Service, Sydney, Australia b
co
py
c
r's
A B S T R A C T
Au
th o
Objective: This integrative review aimed to appraise the evidence for case conferencing as an intervention to improve palliative care outcomes for older people living with advanced dementia in nursing homes. Design:AnintegrativereviewofEnglishlanguagecitationsfromCINHAL,MEDLINE, PSYCHINFOandCareSearchusingapalliativecarefilterwas undertaken.Tworeviewers screened238titlestofind77relevantarticleswhichwerereviewedindetailtoidentify ninestudiesthataddressed thespecificreviewquestions.Theanalysisprocessallowed studycharacteristics,processandoutcomemeasuresalongwithimplementation barriers andfacilitatorstobeidentifiedandtheresultssynthesised. Results:Thehighestlevelofevidence(LevelII)wasgeneratedbytworandomised controlledcaseconferencingtrialswhichdemonstrated enhancemedicationmanagement forpeoplewithdementialivinginanursinghome.Severalpre-postteststudiessuggest thatcase conferencingenhancespalliativesymptommanagementandcareoutcomesin nursinghomes.Qualitativeevidencesuggeststhatcase conferencingisfeasibleand worthwhileiftheidentifiedbarriersareaddressedandthefacilitatorsoptimised. Conclusions:Caseconferencing providesopportunitiestoimprovecarepalliativecare outcomesforolderpeoplewithdementiabyengagingfamilyandallrelevantinternaland externalhealthprovidersinprospectivecareplanning.Moreevidenceisneededto determinetheefficacyandcost-effectivenessofcase conferencingasastrategyfor improvingcareoutcomesforolderpeoplelivingwithadvanceddementiainnursing homes.Theevidence generatedbythisintegrativereviewwillbeofinteresttopolicy makers,agedcareorganisationsandcliniciansalike,especiallyasservices endeavourto meettheincreasinglycomplexcareneedsofolderpeopleadmittedtonursinghomeswith advanceddementia,andtheneedsof theirfamilies.
ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.11.001
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License
2 What is already known about the topic?
r's
1. Introduction
co
That there is evidence that case conferencing improves medication management for people with advanced dementia living in a nursing home. That there is moderate level evidence that case conferencing improves the delivery of a palliative approach to care for people with advanced dementia living in a nursing home. There are a number of facilitators and barriers which impact on the capacity of external medical providers to contribute to interdisciplinary care planning for older people in nursing homes setting. Further research using more robust study designs is required to demonstrate the effectiveness and efficiency of case conferencing as a strategy for improving palliative care outcomes for people with advanced dementia.
py
Advanced dementia is a terminal illness. People with advanced dementia living in nursing homes experience various debilitating symptoms during the last year of life requiring the coordinated input from a range of health professionals. Access to specialist palliative care is limited in this population and setting making the delivery of a palliative approach to care an important priority. What this paper adds
decision-making (Birch and Draper, 2008; Di Giulio et al., 2008). Symptom assessment and management in the context of severe cognitive impairment is complex, especially in the presence of other co-morbid conditions and communication difficulties (Mitchell et al., 2009). Residents’ symptoms such as pain, frequently go unrecognised, under reported and are poorly managed (McAuliffe et al., 2009). People with advanced dementia often experience pneumonia and eating problems requiring focused management and planning (Mitchell et al., 2009). However, diminished verbal communication skills and decision-making capacity, limits residents’ ability to participate in clinical decision making. Medical problems may be inappropriately managed with care escalated to include aggressive treatments such as intravenous antibiotics and hydration and enteral feeding (Sorrell, 2010). Clinically futile treatments compromise residents’ comfort for little or no survival benefit and reduce family satisfaction with end-of-life care (Engel et al., 2006; Givens et al., 2010; Sorrell, 2010). In response to the increasing prevalence of advanced dementia and its adverse impact on decision-making capacity many jurisdictions have introduced legislation that outlines the required approach for managing this populations care needs (Public Guardianship Office, 2005; NSW Guardianship Tribunal, 2011). Depending on the legislation, once a person has been assessed and deemed not to have capacity to make decisions, a specific person is usually nominated to make clinical decisions on behalf of the person with limited capacity (NSW Guardianship Tribunal, 2011). Very often this person is a family member, and their communication with aged care staff and their involvement in decision-making are important factors in determining their satisfaction with care (Engel et al., 2006). Family members have defined a ‘good death’ for residents with advanced dementia as receiving appropriate and timely symptom management, clear decisionmaking, preparation, completion, and affirmation of the whole person (Bosek et al., 2003). Advance care planning has been noted to improve end-of-life care, patient and family satisfaction, and reduces stress, anxiety and depression in surviving relatives. Despite these positive outcomes, too few people with dementia have prospectively documented their end-of-life wishes (Detering et al., 2010); and few nursing homes have effectively embedded advance care planning into routine practice, with the majority tending to initiate discussions about end-of-life treatments late in a resident’s illness as opposed to shortly after their admission (Shanley et al., 2009). In the absence of prospective advance care planning, nursing home personnel are often unwilling or unable to manage complex clinical problems, leading to an acute admission (Mitchell et al., 2007). Hospitalisation is not only frequently frightening for people with dementia, but it is also often associated with iatrogenic events, and is rarely focused on quality of life and is costly (Andrews and Christie, 2009; Hines et al., 2009). Hospitalised patients with dementia are more likely than non-demented patients to have a longer terminal stay, poorer outcomes and less likely to receive palliative treatment or have their families involved in decision-making (Afzal et al., 2010).
Au
th o
Across the developed world dementia is one of the main causes of disability in later life. Current estimates suggest that 3.4 million Americans (2011), almost one million people in the United Kingdom (UK) (Luengo-Fernandez et al., 2010) and a quarter of a million Australians (Access Economics, 2005) have dementia, with the majority having Alzheimer’s Disease (Brookmeyer et al., 2011). The burden of dementia is expected to double in the next 20 years in line with population ageing (Access Economics, 2005). As dementia is a terminal neurological disease which is associated with poor prognostic factors there is a need to optimise the delivery of best evidence based care for this rising population (Ahronheim et al., 1996). Most people with dementia will be managed at home, until their care needs exceed available community resources prompting nursing home admission. Managing advanced dementia in nursing homes is a growing challenge, with more than half of all residents currently admitted having a dementia diagnosis (Access Economics, 2005). Whilst there is substantial evidence to guide dementiaspecific palliative care (Australian Department of Health and Ageing and National Health and Medical Research Council, 2006), many aged care and primary care clinicians lack awareness that a palliative approach is indicated, or find this approach difficult to integrate into dementia care (Hertogh, 2006). Major barriers preventing the delivery of a palliative approach for people with dementia include deficiencies in expertise (Chang et al., 2009), poor communication between services, aged care personnel and/or families, inadequate planning and inconsistent
3 large systematic review found that despite the complexity of addressing the care needs of both people with advanced dementia in nursing homes and their care givers, there was no direct evidence that addresses improving continuity of care for this population at the end-of-life (Lorenz et al., 2008). Since these studies have been undertaken, case conference planning has been promoted as an important element for improving care outcomes for older people with advanced dementia (Australian Department of Health and Ageing and National Health and Medical Research Council, 2006; Australian Government Department of Health and Ageing, 2010).
1.1. Palliative approach A palliative approach aims to improve the quality of life for people with an eventually fatal condition, such as advanced dementia, by reducing suffering through early identification, assessment and treatment of pain, physical, psychological, social, cultural and spiritual needs (Australian Department of Health and Ageing and National Health and Medical Research Council, 2006). In the context of advanced dementia a palliative approach acknowledged the needs of residents and their families and helps facilitate: (i) decision making support and goal setting, including advance care planning; (ii) ensures access to practical aid, community resource and specialist palliative care advice or support as required; and (iii) collaborative and seamless end-of-life care within the care setting of choice (Davidson and Phillips, 2012).
1.3. Case conferencing
Au
co
th o
r's
Addressing the complexity of older peoples’ care needs, reducing care costs, preventing disease exacerbation and common geriatric syndromes such as falls and delirium, which are associated with significant morbidity and mortality, requires an interdisciplinary approach to care (American Geriatrics Society, 2006). Internationally, the value of interdisciplinary care and the importance of prospective individualised care planning for a person with dementia are reflected in various policies and standards (Aged Care Standards and Accreditation Agency, 1997; American Geriatrics Society, 2006). Interdisciplinary care enhances the management of the assessment, planning and delivery of care, which is often complicated by a range of psychosocial concerns and issues (American Geriatrics Society, 2006). In the acute geriatric care setting, interdisciplinary care has resulted in a sustained reduction in mortality, improved functional status and reduction in length of stay and fewer nursing home admissions (To et al., 2010). However, interdisciplinary care is dependent on the establishment of systems that facilitate relevant health professionals’ input and collaboration to provide appropriate support and care to the resident and their family, based on need (American Geriatrics Society, 2006). The configuration and access to medical care in nursing homes vary considerably across the developed world. In the United States (US) onsite physicians are employed directly by nursing homes to manage residents’ medical care, whereas in Australia and the UK, medical care is provided by the resident’s General Practitioner (GP), whose core business is providing care outside of the nursing home, which impacts on their availability. Limited access to medical care can contribute to sub-optimal care planning for older people living in a nursing home with advanced dementia. The development of an interdisciplinary care plan for people living with end-stage dementia in US nursing homes significantly decreased discomfort (Kovach et al., 1996) suggesting that interdisciplinary care planning may improve care outcomes for this population. However the large effect size reported in the Kovach et al. (1996) study may reflect that the research team could not be blinded to the intervention (Hall et al., 2011). A recent
py
1.2. Multi-disciplinary care
Case conferencing is defined as an approach that brings together relevant health professionals and the residents’ primary decision-makers, usually family members, to discuss the current stage of illness and agree on a person-centred management plan based on best available evidenced-based practice (Abernethy et al., 2006). Case conferencing is one option for facilitating the delivery of interdisciplinary care in nursing homes. An Australian palliative care case conferencing randomised control trial, conducted in the community setting and involving a small number of people in nursing homes, demonstrated that it was possible to engage residents, their families, aged care staff and GPs in this type of care planning forum (ShelbyJames et al., 2007). Conferring proof that palliative care case conferencing in nursing homes is both feasible and if planned accordingly can be successfully undertaken. This is an important observation, as case conferencing in the aged care setting has been promoted as a forum for the family, and primary and aged care professionals to collaboratively work through issues and formalise care planning for the resident with dementia (Alzeimer’s Australia, 2009). Adopting a case conferencing format allows for the sharing and consideration of different perspectives regarding what the resident might have wanted, an opportunity to discuss expected changes and for the care team to come to a shared agreement about the goals of care, all of which are important in the presence of advanced dementia. Case conferencing also provides an opportunity for a palliative approach to be adopted by the interdisciplinary team so as to better manage the residents expected illness trajectory, as well as tailoring care to their specific needs and those of their family. 2. Aim This integrative review aimed to synthesise the qualitative and quantitative evidence on case conferencing for older people with advanced dementia living in nursing homes to determine its effectiveness for improving care outcomes and to identify the barriers and facilitators associated with adopting this approach. 3. Method A preliminary search revealed limited studies with heterogeneous methods precluding a systematic review.
4 Scholar and Mednar search engines were undertaken using MeSH keywords including: ‘case conferencing’, ‘care planning’, ‘geriatric’, ‘older people’, ‘residential aged care’, ‘nursing homes’, ‘care homes’, ‘palliative care’, ‘terminal care’, ‘end-oflife care’, ‘community’, ‘primary care’, ‘general practitioner’, ‘dementia’, ‘cognitive impairment’, and ‘Alzheimer’s’. In addition, to hand searching for other potentially relevant articles the palliative care search engine, ‘CareSearch’ (http://www.caresearch.com.au/) was used to identify relevant studies from the grey literature.
An integrative review was deemed to be the most appropriate method because it would facilitate a summation of all past research whilst drawing overall conclusions from the relevant body of literature that address related hypotheses to better understand the phenomena of case conferencing as an strategy for improving palliative care outcomes for people with advanced dementia in nursing homes (Whittemore and Knafl, 2005). This review method is an approach that allows for the synthesis of diverse methodologies such as experimental and non-experimental research into a higher-order theoretical structure through induction and interpretation (Whittemore and Knafl, 2005). Integrative reviews are used to present the state of the science, contribute to theory development and inform policy and practice (Whittemore and Knafl, 2005). The method adopted for this integrative review adhered to the following steps: (i) problem identification, (ii) literature search, (iii) data evaluation, (iv) data analysis and (iv) evaluation and synthesis of the evidence (Whittemore and Knafl, 2005).
3.2. Analysis of the results
Au
co
th o
r's
The purpose of this integrative review was to analyse the evidence of case conferencing as applied to older people with advance dementia living in nursing homes, by answering the following key questions: (a) What is the evidence for case conferencing in nursing homes? (b) What are the key elements of existing models for case conferencing in nursing homes? (c) What are the facilitators and barriers to engaging relevant external health professionals, particularly external medical providers in interdisciplinary case conferencing in nursing homes? and (d) What are the gaps in the evidence and future research directions? A search strategy for this integrative review was developed prior to the review being conducted over the period 1 July 2010–31 December 2010. Published and unpublished English language studies that involved case conferencing as a strategy for improving interdisciplinary care for older people living in nursing homes, enhancing medical decision making and/or engaging primary care in case conferencing were included if they generated descriptive or empirical research evidence. Studies focusing on case conferencing to enhance social care or those underpinned by alternative philosophies such as attachment or validation theory were excluded from this review. Studies were also excluded if they reported on a synthesis of expert opinion(s), were conducted in the acute care setting, and were not in English. If a study was reported more than once, only the primary study was included in the review. The search strategy and retrieval process ensured that a collection of relevant articles from a range of resources including: electronic databases, libraries, journals, conferences, dissertations and manual sources, such as archival material and government reports was obtained (Hunt and McKibbon, 1998; Higgins and Green, 2005). Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL) 1982 – December 2010; Medline 1950 – December 2010; PsycINFO 1806 – December 2010; and CareSearch using a palliative care filter and the World Wide Web using Google
py
3.1. Search strategy and selection criteria
Two evidence evaluation tools developed by the Australian Palliative Residential Aged Care Project (APRAC) Guidelines were used to appraise the studies (Australian Department of Health and Ageing and National Health and Medical Research Council, 2006). The APRAC quantitative studies evaluation tool adopted the Australian National Health and Medical Research Councils (NHMRC) level of evidence categories (National Health and Medical Research Council, 1999) and added an additional level to capture verifiable quality or program evaluation data (Level V evidence) (Stetler et al., 1998). This data extraction tool facilitated a systematic approach to appraising the strength of the evidence, the quality of methods used whilst determining the transferability and applicability of the results to support recommending the implementation of case conferencing in nursing homes. The APRAC qualitative studies levels of evidence (QE) evaluation tool uses eight questions to appraise the aim of the study and the appropriateness of the method (Australian Department of Health and Ageing and National Health and Medical Research Council, 2006). For each included study, data on methods, setting, findings, strength and weaknesses of the approach were extracted onto standard data collection forms by two team members (JP and PW). The appraisal tool sought to document study characteristics, implementation barriers and facilitators and the process and outcome measures identified as well as any reference to case conferencing. Poorly designed studies and those of less relevance to the review questions contributed less to the analysis process (Whittemore and Knafl, 2005). The heterogeneity of studies combined with the small number of relevant studies focusing on case conferencing in nursing homes and/or engaging primary care in the case conferencing process prevented a meta-analysis being undertaken. An overall data analysis classification system was devised, based on chronology, study design, sample characteristics and experience, attitudes or behaviour of participants in relationship to case conferencing in nursing homes. Extracting relevant data and aligning it with specific search question(s) aided data reduction whilst also facilitating the recognition of patterns, themes and clusters (Miles and Huberman, 1994; Whittemore and Knafl, 2005). Comparing and contrasting these data assisted with recognition of the relationship between variability and identifying intervening factors allowing for a logical body of case conferencing evidence to be assembled (Whittemore and Knafl, 2005).
5 system (aged or primary care organisations) levels. The majority (n = 6) of these studies involved residents, aged care personnel, GPs and/or physicians. The number of participants in these studies varied widely, including: residents (range 13–1854); families and caregivers (range 8–58); GPs (range 8–69); nursing homes (range 2–33) and aged care personnel (range 18–302).
4. Results The initial search generated 238 possible research publications, from the following sources: CINHAL (n = 39); MEDline (n = 38); PsychInfo (n = 5); SCOPUS (n = 149) and CareSearch using a palliative care filter (n = 7). Seventyseven studies remained after duplicate studies were removed and the title and abstracts reviewed. Out of these studies, 68 articles were excluded because they did not meet the inclusion criteria. The remaining 9 studies all focused on a specific aspect of interdisciplinary case conferencing in nursing homes (n = 6) (Fig. 1) and/or engaging external medical practitioners in this process (n = 3). The majority (n = 7) of studies were conducted in Australia with the remaining studies undertaken in the USA (n = 1) or Sweden (n = 1).
4.2. Impact of case conferencing on residents and/or family care outcomes
co
th o
r's
The level of evidence generated by each of these studies is summarised in Table 1. The studies in this review included two quantitative studies, four qualitative studies and three mixed method design studies. The highest level of evidence (Level II) was generated by two well designed randomised controlled trials (RCT). Despite no single study specifically addressing all of the questions that this integrative review set out to answer; each study included in the review addressed a particular search question which sought evidence on a specific aspect of multidisciplinary case conferencing in nursing homes. All of the studies included in this review focused on exploring the impact of case conferencing at either the consumer (residents and/or family); health provider (external medical provider or aged care personnel) or
py
4.1. Study characteristics
A Swedish RCT evaluated the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in nursing homes (n = 33) (Schmidt et al., 1998). The intervention nursing homes where regular multidisciplinary team meetings were held had significantly fewer deviations of excessive psychotropic drug prescribing and use at the resident level (p < 0.01) (Schmidt et al., 1998). More acceptable antidepressants prescribing was also noted in the intervention nursing homes (p < 0.001) compared to the control homes (Schmidt et al., 1998). A similar multidisciplinary case conference intervention undertaken in Australia demonstrated an improvement in medication management for nursing home residents in the intervention group (Crotty et al., 2004). In this intervention outreach specialist services provided input to the multidisciplinary case conference without direct patient contact (Crotty et al., 2004). The evidence generated from this cluster RCT verified that multidisciplinary case conferencing improved medication appropriateness (p< 0.001) and reduced the use of benzodiazepines (p = 0.017) in intervention nursing homes (Crotty et al., 2004). However, the intervention did not
Au
Potentially relevant documents identified by literature search (n=238) Documents excluded after evaluation of abstract (n=161)
Documents retrieved for detailed examination (n=77) * Documents excluded did not meet the inclusion criteria (n=70)
Documents included in integrave review (n=7)
Documents included in review aer hand search (n=2)
Total documents included in integrave review (n=9) Fig. 1. Flow chart of studies from search to inclusion.
6 Table 1 Summary table. Level evidence
Focus – nursing homes
Design
Participants and setting
Outcomes
Features
Parker and Hughes (2010) Australia
IV
To develop and implement a comprehensive evidence based palliative approach in aged care
Mixed methods pre-post test design. Multiple measures at the consumer, health professional and system level
Residents (n = 73), carers (n = 55), aged care staff (302) and GPs (n = 69) across nine nursing homes in Australia
This multifaceted intervention involving: education; case conferencing; and; introduction of an end of life care pathway
Halcomb et al. (2009) Australia
QE
Explores consumers, health professionals and managements understanding and perceptions of, multidisciplinary case conferencing in nursing homes
Thematic analysis of focus groups and in-depth interviews of health professionals, residents and families (N = 46)
Abbey et al. (2008) Australia
IV
To develop a structured model of multi-disciplinary palliative care for people with end-stage dementia living in a nursing home
95% of recruited residents had a case conference. The time between the case conference and death was 18 days (IQR = 70.5), range 1–161 days. For 42% of residents still alive at the end of data collection the median number of days between palliative care case conference (or initial recruitment) and end of data collection was 134 days (IQR = 83.0) and the range was 49–259 days. GPs participated in 55% of all case conferences, families in 94% of case conferences and residents in 20% of the case conferences Four themes emerged from the data: (1) confusion over the role of case conferencing; (2) unclear role descriptions for participants; (3) lack of a collaborative culture; and (4) need for a framework to support the organisation of the conference This study suggests some improvement through implementing a model of multidisciplinary care for older people with dementia in residential aged care facilities was achieved. Unable to confirm due to limited statistical data
co py
Source
Au th o
r's
Nurses (n = 17), residents (n = 13), family carers (n = 8) and GP (n = 8) from two nursing homes in Sydney, NSW
3 phase mixed methods study: Phase 1: chart audit (n = 25) and semi-structured interviews with family/carers (n = 25) to determine end-of-life care experience for residents with advanced dementia; Phase 2: pre and post test survey aged care personnel’s palliative care knowledge and attitudes; and Phase 3: carer satisfaction (n = 17) measured ‘Satisfaction with Care at the End-of-Life in Dementia’ tool
Residents from two nursing homes who had a diagnosis of advanced dementia, their carers and aged care personnel.
Multiple barriers identified plus a need for: a well defined case conferencing framework; and greater organisational support to facilitate effective case conferencing
Need for enhanced multidisciplinary care and case conferencing capabilities in nursing homes Establishment of a death review process, involving audits that contributes to the QI agenda
7 Table 1 (Continued ) Level evidence
Focus – nursing homes
Design
Participants and setting
Outcomes
Features
Forbes-Thompson and Gessert (2005) USA
QE
Exploration of the experience of dying in two nursing homes from the perspective of residents, family and staff
A qualitative case study design. Formal and informal interviews, participant observation and document review
56 declining residents from 2 nursing homes were followed until death or for six months, whichever occurred first
Describes case conferencing processes and attendees
Crotty et al. (2004) Australia
II
Evaluation of multidisciplinary case conferencing on medication management and resident behaviours in high care nursing homes
Cluster-randomised control trial involving 10 high care nursing homes: control (n = 54), intervention (n = 50) and within-facility control group (n = 50). As part of the intervention, two multidisciplinary case conferences, involving the resident’s GP, a geriatrician, a pharmacist and aged care personnel, were held for each resident at baseline and repeated 6–12 weeks later
Schmidt et al. (1998) Sweden
II
To evaluate the impact of regular multi-disciplinary interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes
Outcomes relating to residents’ satisfaction with care and quality of life whilst approaching death were substantially different in the two facilities. Better outcomes achieved in the nursing homes utilising a regular multidisciplinary case conferencing approach compared to care planning undertaken by an individual team member 45 died before follow-up. Medication appropriateness improved in the intervention group [X change 4.1, 95% confidence interval (CI) compared to the control group (X change 0.4, 95% CI 0.4–1.2; p < 0.001). Significant reduction in use of benzodiazepines (mean change control 0.38, 95% CI 1.02–0.27 versus intervention 0.73, 95% CI 0.16–1.30; p = 0.017). Resident behaviours unchanged after the intervention and the improved medication appropriateness did not extend to the within control residents. Multidisciplinary case conferencing in RACF can reduce inappropriate medication use Experimental nursing homes with a multidisciplinary team had significantly fewer deviations of excessive psychotropic drug prescribing and use at the resident level (p < 0.01). Orders for more acceptable antidepressants also increased in the experimental homes (p < 0.001). In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes
co py
Source
Au th o
r's
High care residents (n = 154) with medication problems and/or had challenging behaviours
Randomised control trial. Experimental homes (n = 15) participated in an outreach program designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses’ assistants. Multidisciplinary team meetings held regular during 12-month study. Emphasis was placed on adhering to prescribing (SMPA) guidelines
Nursing homes (n = 33): experimental (n = 15) and control (n = 18). Long-term care residents (n = 1854): X age 83 years. 70% female, 42% dementia, 5% psychotic disorder, and 7% had depression.
Medication review prior to case conference Patient and family members not involved in case conference
Multidisciplinary team meetings can improve the selection of psychotropic drugs in accordance with defined clinical guidelines and improve teamwork
8 Source
Level Focus – external medical providers Design evidence
Participants and setting
Outcomes
Mitchell et al. (2002) Australia
QE
GPs’ work practices militated against participation in traditionally structured case conferences. Reimbursement items need to be expanded to cover alternative methods of liaison, such as phone consultations with service providers 25 of the original 30 GPs Despite increasing involved in the 1st study reimbursement item uptake, the actual number performed per GP remained low with 11 being claimed during the previous 12 months. Most claims were for elderly patients with multiple problems and patients with chronic pain and musculoskeletal problems. Those that had claimed a reimbursement were generally positive about their use for care planning and case conferencing GPs (n = 30) providing care Implementation of the across community care reimbursement items settings facilitated integration between GPs and other health professionals, but depended on other forms of integration to succeed. Required a facilitator and structured framework to assist their implementation
Features
Qualitative study, GPs providing care across involving semi-structured community care settings questions administered to focus groups of GPs (n = 29)
Case conference barriers and facilitators identified GPs prefer that specialist groups arrange case conferences, which may have implications for aged care A complicated reimbursement process acts as a disincentive to claim
Blakeman et al. (2002) QE Australia
To re-examine GPs experiences with case conferencing reimbursement items and strategies that have influence their uptake, 12 months after an original study
Repeat semi-structured interviewed at 12 months using a structured questionnaire
Not specific to aged care but identifies a range of case conferencing barriers and facilitators from the GP perspective
Blakeman et al. (2001) QE Australia
Evaluating GPs views on reimbursement items for care planning and case conferencing
Qualitative study, conducting semi structured face to face interviews with GPs regarding care planning and case conferences, pre implementation of reimbursement items
Au th o
r's
co py
To identify GPs views barriers to using case conferencing (across primary care settings – community and nursing homes) and to develop a set of principles to encourage greater case conference participation
Identified specific barriers to GPs participating in case conferencing and the uptake of EPC items Identifies need for MDT education
Evidence levels: I (32) – systematic review of all relevant RCTs; II (32) – at least one properly designed RCT; III-1 (32) – well designed pseudo-RCTs; III-2 (32) – comparative studies with concurrent controls and allocation not randomised, case control studies or interrupted time series with a control group; III-3 (32) – comparative studies with historical and allocation not randomised, case control, two or more single-arm studies or interrupted time series without a parallel control group; IV (32) – case series, either post-test or pre-test and post-test; V (33) – case report or systematically obtained verifiable quality or program evaluation data; QE (31) – qualitative evidence.
9 Table 2 The facilitators and barriers for aged and primary care providers participating in case conferencing. Facilitators
Barriers
Aged care Collaborative problem-solving with other health care providers (Blakeman et al., 2002) Improves communication with other health care providers (Blakeman et al., 2002) Enhances relationships with other health care providers (Blakeman et al., 2002) A nominated case conference coordinator (Blakeman et al., 2001, 2002) Ability to participate via teleconference (Blakeman et al., 2002) Primary care Greater willingness to participate when there is a clear clinical need for case conferencing (Crotty et al., 2004) Availability of remuneration items (Crotty et al., 2004)
Aged care Limited formal communication and multidisciplinary care planning in aged care facilities (Crotty et al., 2004) No funding model that supports a routine multidisciplinary case conferencing approach in aged care facilities (Crotty et al., 2004) Organisation and coordination time constraints (Crotty et al., 2004)
used defined triggers for identifying residents who may benefit from case conferencing as part of a palliative approach (Parker and Hughes, 2010). However, the defined triggers were not provided, making it difficult to draw conclusions about their relevance and applicability outside of the study setting. Few of these published studies provided sufficient details to accurately determine the case conferencing model adopted. One study held a regular multidisciplinary team meeting, but the frequency of the meetings or the length of time devoted to discussing residents care needs were not provided (Schmidt et al., 1998). In another study, a case conference was held at two points in time for each resident; once at baseline and repeated 6–12 weeks later (Crotty et al., 2004). Only two studies explicitly provided opportunities to include residents and family members in the case conferencing meetings (Forbes-Thompson and Gessert, 2005; Parker and Hughes, 2010). However, only a very small proportion (5%) of residents were well enough to participate in the case conference (Parker and Hughes, 2010). One study provided insights into when case conferences were undertaken in the illness trajectory, with the median number of days between the palliative care case conference (or initial recruitment if they died prior to the case conference or did not have a case conference) and death being 18 days (IQR = 70.5) (Parker and Hughes, 2010). For the 42% of residents still living at the end of data collection period, the median number of days between the palliative care case conference (or initial recruitment) and end of data collection was 134 days (IQR = 83.0, range 49– 259 days) (Parker and Hughes, 2010). This suggests that, for the majority of residents, the case conference was
Au
th o
r's
change resident behaviours and the improved medication appropriateness did not extend to the residents in the within control group (Crotty et al., 2004). Two mixed methods studies evaluating the impact of multifaceted interventions to promote the delivery of a palliative approach in Australian nursing homes found high levels of participant support for case conferencing and evidence that case conferencing improved resident outcomes (Abbey et al., 2008; Parker and Hughes, 2010). In both of these pre-post test studies the lack of controls negated the investigators’ capacity to confirm causality. Similarly, another mixed methods study found better outcomes were achieved in the nursing home utilising a regular multidisciplinary case conferencing approach (Forbes-Thompson and Gessert, 2005). In this study, there was a perception that multidisciplinary case conferencing was more beneficial than care planning undertaken by an individual team member, which tended to be more reactive and less collaborative (Forbes-Thompson and Gessert, 2005), but these results cannot be generalised.
co
Advance notice allows scheduling of case conference (Blakeman et al., 2002) Capacity to optimise a multi-disciplinary approach with input from relevant health providers (e.g. geriatricians, pharmacists) (Crotty et al., 2004; Goodman et al., 2010) Opportunity to participate in case conferences prior to resident’s acute care discharge
py
Process to routinely identify patients requiring a case conference (Crotty et al., 2004) Case conference facilitation support (Crotty et al., 2004) Arranging several sequential case conferences (Crotty et al., 2004)
Primary care Uncertainty about the skills and qualities required for effective MDT functioning (Halcomb et al., 2009) Limited infrastructure to support inter-sectorial collaboration (Halcomb et al., 2009) Time constraints and inadequate communication limit GPs case conferencing participation (Blakeman et al., 2001, 2002) Inadequate feedback following referral (Blakeman et al., 2001) Inadequate knowledge about availability and access to relevant community services (Blakeman et al., 2001) Others’ lack of understanding that the GP may perceive their role as the main care coordinator (Blakeman et al., 2001) GPs understanding of the roles of other health professionals and how these roles interface (Blakeman et al., 2001; Halcomb et al., 2009)
4.3. Case conference focus and format The focus of studies included in this review tended to be on adopting a case conferences format to address a specific aged care issue, such as: appropriate medication management (Schmidt et al., 1998; Crotty et al., 2004); managing challenging behaviours (Crotty et al., 2004); advanced dementia management (Abbey et al., 2008); providing a palliative approach (Abbey et al., 2008; Parker and Hughes, 2010); or planning end-of-life care (Forbes-Thompson and Gessert, 2005). The inclusion criteria adopted by one study
10 actually being held in the weeks immediately prior to their death.
5. Discussion
co
th o
r's
A range of facilitators and barriers related to engaging aged and/or primary care providers in case conferencing in nursing homes have been identified, but all of the evidence identified was generated in Australia, a country with a universal health care system which has funding drivers in place to promote case conferencing in the primary care setting (refer Table 2). Within this context, the potential benefits of GPs using available reimbursement items include: creating time and structure to deal with complex cases, formalise existing work, facilitating a holistic approach to patient care, and encouraging contact with other healthcare professionals (Blakeman et al., 2002; Crotty et al., 2004; Goodman et al., 2010). Uptake of case conferencing was also facilitated by ensuring organisational and administrative support, with special attention to GP involvement (Mitchell et al., 2002; Crotty et al., 2004). For aged care providers, case conferencing is an opportunity for collaborative problem solving (Blakeman et al., 2002). The indentified barriers to case conferencing from the perspective of the GP included: time constraints, language barriers related to dealing with people from non-Englishspeaking backgrounds, other health professionals’ lack of knowledge of the reimbursement items, GPs’ lack of understanding of other disciplines’ roles, and the importance of collaborative care planning (Blakeman et al., 2001, 2002; Halcomb et al., 2009).
py
4.4. Barriers and facilitators
people with dementia living in nursing homes, particularly in the areas of: advance care planning; better physical symptom management; psychological support; family support; and terminal care (Abbey et al., 2008; Parker and Hughes, 2010). But additional research using more robust designs is needed to confirm these observations. A recently completed pre-post test study included case conferencing as part of a larger multi-faceted intervention which aimed to embed evidence based palliative approach within the nursing home setting (Parker and Hughes, 2010). Participation in a palliative care case conference held in nursing homes improved families’ satisfaction in regard to communication, particularly with GPs (Parker and Hughes, 2010). The introduction of case conferences was perceived to have contributed to improving the quality of clinical care for residents in the participating nursing homes, taking into account their personal preferences whilst also improving aged care personnel’s clinical and multidisciplinary team capabilities (Parker and Hughes, 2010). However, the absence of study controls precludes any definitive conclusions from being drawn about the effectiveness of case conferencing on resident’s palliative care outcomes. Despite the limited high level evidence for the implementation of case conferencing in nursing homes for people with advanced dementia, there is evidence that palliative care case conferencing is effective in other community settings (Shelby-James et al., 2007; Mitchell et al., 2008). An RCT conducted across a regional Australian community palliative care setting demonstrated that case conferencing was feasible, and this process facilitated greater GP engagement and enhanced patient centred care planning (Shelby-James et al., 2007). However, a similar multi-centred case conferencing RCT involving specialist palliative care teams and GPs reported mixed results (Mitchell et al., 2008). Despite no detected difference in global quality of life scores three weeks post case conference, significant improvements were reported in the domains of patient’s physical and mental wellbeing at fixed points, 35 and 14 days pre death in the case conferencing group (Mitchell et al., 2008). In addition, positive impacts for carers were reported, with significantly lower carer burden in two of five domains and a trend in favour of the intervention group in the impact on caregivers’ health (Mitchell et al., 2008). The degree to which this high level case conferencing evidence is applicable and transferable to a nursing home population is unknown. Particularly, as both RCTs were undertaken in the specialist palliative care community setting with cognitively intact adults who predominantly had cancer, making it difficult to generalise the results to people with advanced dementia living in nursing homes. The unique management needs of people with advanced dementia, such as aspiration, pneumonia and eating problems, and the specific skills required to support families when the person with dementia may have limited ability to communicate their needs and participate in care decisions, needs to be taken into consideration in any future case conferencing RCTs in nursing homes. In the aged care setting, access to timely medical care is a major concern for residents and their families and aged
Au
Managing the needs of people with advanced dementia is complex and demands a multidisciplinary team approach. Achieving this requires a range of professionals to work collaboratively with the resident and their family to establish agreement on the goals of care and to address their care needs. Despite the increasing number of people admitted to nursing homes with advanced dementia this review found few studies that explicitly explored the impact of case conferencing on palliative care outcomes for this population. Despite this limitation, this integrative review generated valuable insights into the role of case conferencing in nursing homes and provided information in relation to each of the review questions. 5.1. What is the evidence for case conferencing in nursing homes? As case conferencing in nursing homes has often been implemented as one discrete element within a multifaceted intervention it is difficult to draw definitive conclusions about its impact on resident’s care outcomes. However, there is high level evidence that case conferencing in nursing homes can improve medication management outcomes for residents (Schmidt et al., 1998; Crotty et al., 2004). There is also lower level evidence that case conferencing can improve palliative care outcomes for
11 Table 3 Suggested strategies to optimise case conferencing participation. Strategy
Rationale and action
Optimising GPs input
Scheduling the case conference around GP availability (Crotty et al., 2004) Arranging the case conference 10–14 days in advance (Blakeman et al., 2002; Crotty et al., 2004) Prior identification of residents’ problem(s) and/or care needs (Crotty et al., 2004) Arranging a ‘block’ of case conferences for individual GPs (Crotty et al., 2004) Teleconferencing in relevant health professionals (Crotty et al., 2004)
Creating an individual multi-disciplinary team with the capacity to meet each residents care needs
Develop criteria to determine when residents and family ought to be present at a case conference (Crotty et al., 2004) Providing the practical infrastructure to support collaborative care between private, state and commonwealth health care sectors (Halcomb et al., 2009)
Resident and family participation
Strongly recommended whenever possible (Abbey et al., 2008)
co
py
to engage GPs in well organised and focussed aged care case conferences. A family member was nearly always present, reinforcing the value families place on contributing to the care planning process and having an opportunity to have their questions answered. The capacity of only a small proportion of residents being able to participate in their own case conference may reflect the level of fragility and/or the severity of cognitive impairment experienced by this population in the months and weeks preceding their death (Parker and Hughes, 2010). It could not be determined whether the limited allied health input into the case conference (Parker and Hughes, 2010) reflects residents’ care needs or allied health workforce shortages, and/or the challenges and costs associated with securing allied health input, who often provide services as external providers, precluding a higher level of involvement. Several studies identified the need for greater education of health professionals involved in case conferencing to ensure that participants fully optimised the opportunities afforded by this type of care planning forum (Blakeman et al., 2001; Abbey et al., 2008; Halcomb et al., 2009). In an attempt to address this identified knowledge-practice gap various palliative approach case conferencing toolkits have been developed. The most recently developed toolkit includes a range of resources, including: generic policy templates, a DVD about establishing and conducting case conferences in aged care, and self-directed learning packages (Parker and Hughes, 2010). The information contained within this toolkit provides aged care providers with a step-by-step account of the action required to implement effective case conferencing processes within their facility. The key elements emerging from this review of case conferencing in nursing homes includes the need to develop strategies to ensure: an interdisciplinary approach, ideally involving all relevant health professionals, particularly GPs and other external medical providers; systematizing processes; a clearly defined focus; and linking the case conferencing to existing funding processes. In Australia, additional aged care funding is currently available to support the care of residents with demonstrated intensive nursing or complex pain management needs. A case conference that includes expert advice from a palliative care or pain
th o
r's
care staff. Despite a range of reimbursement items being available to better support Australian GPs to continue to provide medical care to their patients living in nursing homes, their uptake has been very limited (Harris, 2002). The evidence emerging from this review suggests that the collaborative development of systematic case conferencing processes can increase GP engagement in planning residents care (Australian Government, 2010). In the Australian context, GPs involvement in care planning is critical to the capacity of the nursing home to claim additional funding to better support residents with complex care or palliative care needs (Parker and Hughes, 2010). These financial incentives may explain the high numbers of Australian studies available for this review. 5.2. What are the key elements of existing models for case conferencing in nursing homes?
Au
The principles underpinning interdisciplinary case conferencing in nursing homes for people with advanced dementia appear to be largely poorly understood by many primary and aged care personnel (Blakeman et al., 2002; Halcomb et al., 2009). A qualitative study exploring key stakeholders’ perceptions and understanding of aged care multidisciplinary case conferencing identified: (1) confusion over the role of case conferencing; (2) unclear role descriptions for participants; (3) lack of a collaborative culture; and (4) the need for a framework to support the organisation of the case conference (Halcomb et al., 2009). Suggesting that more work at the health provider and organisational level is required to facilitate effective case conferencing in nursing homes. Few of the studies included in this integrative review provided details of the case conferencing format, time allocated for each case conference or the composition of the interdisciplinary team members participating in the case conference. The most recent study by Parker and Hughes (2010) reports that the majority of participating residents had a palliative care case conference within 18 days of their death and that few residents had neither GP nor a specialist palliative care nurse input into the case conference, with just over half of all residents’ GPs participating. This finding demonstrates that it is possible
12 specialists meets this requirement, making it potentially a power driver for the systematic implementation of case conferencing for nursing home residents with complex care needs.
co
5.4. What are the gaps in the evidence and future research directions?
Au
th o
r's
In the nursing home setting, case conferencing is perceived to optimise the capacity for a multidisciplinary approach to care by facilitating the attendance and contribution of relevant disciplines, such as: GP, geriatrician, pharmacist, allied health and nursing staff, many of whom are not employed directly by the organisation (Crotty et al., 2004; Goodman et al., 2010). If well organised, interdisciplinary case conferencing provides an opportunity to improve communication and collaborative problem solving (Crotty et al., 2004). A defined case conference agenda is an important facilitator, especially as aged care personnel and GPs typically only meet for brief ad hoc periods to plan residents care, and frequently via phone (Crotty et al., 2004). Arranging off-site medical input into residents’ case conferences can be challenging given GPs workloads, but GP participation occurs more frequently if there is a coordinator, who arranges the entire process (Blakeman et al., 2001, 2002), and there is a clearly identified need for the case conference (Crotty et al., 2004) and GPs are given advance notice (Blakeman et al., 2002). Ideally, GPs would prefer to be included in a case conference prior to the resident’s discharge from acute care (Blakeman et al., 2002). Arranging sequential blocks of residents requiring a case conference has been identified as a strategy to increase individual GP participation in individual nursing homes (Crotty et al., 2004). There is mixed evidence regarding GPs’ preferences for teleconferencing versus face-to-face case conference participation. Whilst some GPs prefer to participate via a teleconference, because it negates the need to leave the surgery (Blakeman et al., 2002), others prefer to participate in person (Parker and Hughes, 2010). Reimbursement items were designed to increase GP participation in case conferences (Crotty et al., 2004), but the limited uptake of these items in Australia suggest that financial reward is not the main driver for participation (Wilkinson et al., 2003; Phillips et al., 2009). Whereas addressing the time constraints, which are frequently cited by aged and primary care providers as a major barrier to case conferencing participation, may result in greater GP input (Blakeman et al., 2001, 2002; Crotty et al., 2004). Arranging case conferences for people from nonEnglish-speaking backgrounds has also been identified as challenging (Blakeman et al., 2001). As one in eight people with dementia in Australia do not speak English at home (Access Economics, 2006) addressing their needs in the context of case conferencing is a important priority. The challenges are amplified with people with dementia who frequently revert to their first language making it difficult to address their individual care needs in the absence of an interpreter (Access Economics, 2006).
py
5.3. What are the facilitators and barriers to engaging external health professionals in interdisciplinary case conferencing in nursing homes?
Under resourcing in nursing homes not only contributes to staff being time poor, but the scarcity of resources limits the organisations’ capacity to implement a routine multidisciplinary case conferencing approach to plan care for all residents (Crotty et al., 2004). Even with a designated case conference coordinator, identifying and scheduling time for health professionals and families and/ or residents to participate in a case conference is a timeconsuming and challenging process (Crotty et al., 2004). If a case conference runs over the allocated time, health professionals may be reluctant to participate again (Blakeman et al., 2001, 2002; Crotty et al., 2004). Streamlining and refining the case conferencing processes appear to be critical to successful implementation. Role ambiguity has also been identified as another barrier, especially if the GP perceives they are the resident’s main care coordinator (Blakeman et al., 2001) or if the GP has a limited understanding of the roles of other health professionals and how the various roles interface to optimise care outcomes (Blakeman et al., 2001; Halcomb et al., 2009). The lack of formal training and understanding of interdisciplinary care planning processes in aged and primary care are considerable barriers to effective case conferencing (Crotty et al., 2004). However, there is evidence that targeted education and the use of structured processes and templates can help build aged care providers’ capacity and confidence to facilitate case conferences (Parker and Hughes, 2010) (Table 3).
The major gap identified in this review is the lack of high level evidence demonstrating the effectiveness of case conferencing on residents’ care outcomes; as well as its impact on communication between services, aged care personnel and families; and capacity to reduce inconsistency in decision-making. Despite case conferencing having resulted in improved outcomes in other palliative settings, evidence is lacking for residential aged care residents with advanced dementia. However, the case conferencing interventions were generally poorly described making it difficult to replicate in subsequent studies. The heterogeneity of the studies and the absence of raw data also limit opportunities for future meta-analysis. Given the significant investment, in terms of time and resources required to operationalise case conferencing in this complex care setting, well-designed controlled clinical trials are required to compare the efficacy and costeffectiveness of case conferencing with usual care in nursing homes. Generating this type of evidence is critical to informing future aged care policy, standards and practices. If case conferencing is found to be effective then embedding case conferencing within best practice recommendations will be a powerful driver for change and increase the rate at which this evidence is translated into practice. 6. Study limitations and strengths The exclusion of studies not published in English, the absence of multiple independent raters to assess eligibility
13 Conflict of interest
and quality of the included studies may have contributed to selection bias. By focusing exclusively on ‘case conferencing’ as a potential strategy for enhancing the delivery of a palliative approach to older people with advanced dementia living in a nursing home this integrative review has limited the ability to identify other strategies that also promote interdisciplinary care planning and greater engagement of external medical providers. However, by focusing on the phenomena of case conferencing the integrative review has provided valuable insights into the role of this approach and identified the barriers and facilitators that need to be considered prior to introducing this type of interdisciplinary care planning into practice. Undertaking an integrative review and successfully combining diverse data is a complex and challenging process (Whittemore and Knafl, 2005), which makes following a rigorous process a priority. Adoption of a systematic approach which allowed for the inclusion of a wide range of study designs whose quality was appraised using a structured method is a considerable strength of this review.
None declared. Contributors JP, MA and PD were responsible for the study conception. JP and PW drafted the manuscript. JP and PW undertook the literature search and integrative review. MA & PD reviewed and commented on the findings. MA obtained funding. PD and MA provided expert advice. JP made critical revisions to the paper. Acknowledgements This research was funded by the Department of Health and Ageing, Local Palliative Care Grants – Round 5 and was undertaken, in part, with funding support from the Cancer Institute New South Wales Academic Chairs Program.
py
References
Au
th o
r's
Given the complexity of managing the care needs of older people with advanced dementia and their families seeking consensus on the goals of care and developing an agreed plan of care is an important priority. Case conferencing combines interdisciplinary assessment and care planning, to achieve negotiated outcomes. It is a process that positions advanced dementia as a terminal illness and allows the team and family to plan accordingly. Case conferencing can improve care for older people with advance dementia by facilitating better communication and coordination; increasing the uptake of appropriate symptom management strategies and decreasing unnecessary hospitalisations; and promoting seamless transitions in care if hospital admissions are necessary. It also offers the possibility of better engaging primary care, aged care professionals, residents and their carers in a collaborative care planning process. Involving family members and wherever possible the residents, depending on their capacity to participate is a key consideration, particularly given the importance of ensuring an integrated approach to direct care and advance care planning. Case conferencing allows the interdisciplinary team to prospectively plan to effectively manage the older person’s end-of-life care within the nursing home. Effective case conferencing engages all relevant internal and external team members in accordance with the older person’s care needs. The barriers and facilitators to establishing case conferencing in nursing homes suggest that with good planning and coordination and appropriate case conferencing can be readily established in this care setting. Despite significant policy support for case conferencing in some countries more evidence is needed to determine the efficacy and cost-effectiveness for aged care residents with advanced dementia. Developing the evidence base for case conferencing for older people with advanced dementia in aged care is an important next step towards improving care outcomes.
Abbey, J., Sacre, S., et al., 2008. Develop, Trial and Evaluate a Model of Multi-disciplinary Palliative Care for Residents with End-stage Dementia. The Prince Charles Hospital Foundation & Queensland University of Technology, Brisbane. Abernethy, A.P., Currow, D.C., et al., 2006. A pragmatic 2 2 2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care-methodology of the Palliative Care Trial [ISRCTN 81117481]. Contemporary Clinical Trials 27, 83–100. Access Economics, 2005. Dementia Estimates and Projections, NSW and its Regions. Report for Alzheimer’s Australia, NSW and NSW Health Report for Alzheimer’s Australia, NSW and NSW Health Canberra. Access Economics, 2006. Dementia prevalence and incidence among Australians who do not speak English at home Melbourne Alzheimer’s Australia. Afzal, N., Buhagiar, K., et al., 2010. Quality of end-of-life care for dementia patients during acute hospital admission: a retrospective study in Ireland. General Hospital Psychiatry 32, 141–146. Aged Care Standards and Accreditation Agency, 1997. Accreditation Standards. Aged Care Standards and Accreditation Agency, Canberra. Ahronheim, J.C., Morrison, R.S., et al., 1996. Treatment of the dying in the acute care hospital: advanced dementia and metastatic disease. Archives of Internal Medicine 156, 2094–2100. Alzeimer’s Australia, 2009. Position Statement on Palliative Care and Dementia. , From.http://alzeimers.org.au/upload/PalCareStatementFeb09.pdf (retrieved 27.08.10). American Geriatrics Society, 2006. Interdisciplinary care for older adults with complex needs: American Geriatrics Society Position Statement. Journal of the American Geriatrics Society 54, 849–852. Andrews, J., Christie, J., 2009. Emergency care for people with dementia. Emergency Nurse 17, 12. Australian Department of Health and Ageing and National Health and Medical Research Council, 2006. Guidelines for a Palliative Approach in Residential Aged Care – Enhanced Version. E. C. University, ACT, Canberra. Australian Government, 2010. The Changes to Medicare Primary Care Items: A Fact Sheet for General Practitioners. , From.http:// www.health.gov.au/internet/main/publishing.nsf/Content/ A7D118B45060743ECA257743000BE3D3/$File/GPfactsheet.pdf (retrieved 11.09.11). Australian Government Department of Health and Ageing, 2010. Decision-making Frameworks in Advanced Dementia. Australian Government Department of Health and Ageing, Canberra. Birch, D., Draper, J., 2008. A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia. Journal of Clinical Nursing 17, 1144–1163. Blakeman, T.M., Harris, M.F., et al., 2001. Evaluating general practitioners’ views about the implementation of the enhanced primary care medicare items. Medical Journal of Australia 175, 95–98. Blakeman, T.M., Zwar, N.A., et al., 2002. Evaluating general practitioners’ views on the enhanced primary care items for care planning and case
co
7. Conclusion
14
co
py
Luengo-Fernandez, R., Leal, J., et al., 2010. Dementia 2010. H. E. R. C. U. o. Alzheimer’s Research Trust, Oxford. McAuliffe, L., Nay, R., et al., 2009. Pain assessment in older people with dementia: literature review. Journal of Advanced Nursing 65, 2–10. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis. An Expanded Sourcebook. Sage, Thousand Oaks, California. Mitchell, G., de Jong, I.C., et al., 2002. General practitioner attitudes to case conferences: how can we increase participation and effectiveness? Medical Journal of Australia 177, 95–97. Mitchell, G.K., Del Mar, C.B., et al., 2008. Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003). Palliative Medicine 22, 904–912. Mitchell, S.L., Teno, J.M., et al., 2007. Decisions to forgo hospitalization in advanced dementia: a nationwide study. Journal of the American Geriatrics Society 55, 432–438. Mitchell, S.L., Teno, J.M., et al., 2009. The clinical course of advanced dementia. New England Journal of Medicine 361, 1529–1538. National Health & Medical Research Council, 1999. A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. ACT, Commonwealth of Australia, Canberra. NSW Guardianship Tribunal, 2011. Information – Person Responsible N. G. Tribunal. NSW, NSW Guardianship Tribunal, Sydney. Parker, D., Hughes, K., 2010. Comprehensive Evidence-based Palliative Approach in Residential Aged Care. Encouraging Best Practice in Residential Aged Care Program – Round 2. Australian Government, Department of Health and Ageing. The University of Queensland/Blue Care Research & Practice Development Centre, Brisbane. Phillips, J.L., Davidson, P.M., et al., 2009. An insight into palliative care practice in residential aged care: the general practitioner perspective. Journal of Applied Gerontology 28, 395–405. Public Guardianship Office, 2005. Mental Capacity Act 2005: Code of From.http://webarchive.nationalarchives.gov.uk/ http:// Practice. www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf (retrieved 06.08.12). Schmidt, I., Claesson, C.B., et al., 1998. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Journal of the American Geriatrics Society 46, 77–82. Shanley, C., Whitmore, E., et al., 2009. Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device. Australasian Journal on Ageing 28, 211–215. Shelby-James, T.M., Currow, D.C., et al., 2007. Promoting patient centred palliative care through case conferencing. Australian Family Physician 36, 961–964. Sorrell, J.M., 2010. Use of feeding tubes in patients with advanced dementia: are we doing harm? Journal of Psychosocial Nursing and Mental Health Services 48, 15. Stetler, C.B., Morsi, D., et al., 1998. Utilization-focused integrative reviews in nursing service. Applied Nursing Research 11, 195–206. To, T.H.M., Davies, O.J., et al., 2010. Multidisciplinary care needs in an Australian tertiary teaching hospital. Australian Health Review 34, 234–238. Whittemore, R., Knafl, K., 2005. The integrative review: updated methodology. Journal of Advanced Nursing 52, 546–553. Wilkinson, D., Mott, K., et al., 2003. Evaluation of the Enhanced Primary Care (EPC) Medicare Benefits Schedule (MBS) Items and the General Practice Education, Support and Community Linkages Program (GPESCL): Final Report Canberra Commonwealth Department of Health and Ageing.
Au
th o
r's
conferencing. A one year follow up. Australian Family Physician 31, 582–585. Bosek, M.S.D.W., Lowry, E., et al., 2003. Promoting a good death for persons with dementia in nursing facilities: family caregivers’ perspectives. JONA’S Healthcare Law, Ethics and Regulation 5, 34. Brookmeyer, R., Evans, D.A., et al., 2011. National estimates of the prevalence of Alzheimer’s disease in the United States. Alzheimer’s and Dementia 7, 61–73. Chang, E., Daly, J., et al., 2009. Challenges for professional care of advanced dementia. International Journal of Nursing Practice 15, 41–47. Crotty, M., Halbert, J., et al., 2004. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age and Ageing 33, 612–617. Davidson, P.M., Phillips, J.L., 2012. In: O’Connor, M., Lee, S., Aranda, S. (Eds.), Palliative Care in Chronic Illness. Palliative Care Nursing: A Guide to Practice. Ausmed, Melbourne. Detering, K.M., Hancock, A.D., et al., 2010. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. British Medical Journal 340. Di Giulio, P., Toscani, F., et al., 2008. Dying with advanced dementia in long-term care geriatric institutions: a retrospective study. Journal of Palliative Medicine 11, 1023–1028. Engel, S.E., Kiely, D.K., et al., 2006. Satisfaction with end of life care for nursing home residents with advanced dementia. Journal of the American Geriatrics Society 54, 1567–1572. Forbes-Thompson, S., Gessert, C.E., 2005. End of life in nursing homes: connections between structure, process, and outcomes. Journal of Palliative Medicine 8, 545–555. Givens, J.L., Jones, R.N., et al., 2010. Survival and comfort after treatment of pneumoniainadvanceddementia.ArchivesofInternalMedicine170,1102. Goodman, C., Evans, C., et al., 2010. End of life care for community dwelling older people with dementia: an integrated review. International Journal of Geriatric Psychiatry 25, 329–337. Halcomb, E.J., Shepherd, B.M., et al., 2009. Perceptions of multidisciplinary case conferencing in residential aged care facilities. Australian Health Review 33, 566–571. Hall, S., Kolliakou, A., et al., 2011. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database Of Systematic Reviews (Online) 3. Harris, M., 2002. Case conferences in general practice: time for a rethink? Medical Journal of Australia 177, 93–94. Hertogh, C.M.P.M., 2006. Advanced care planning and the relevance of a palliative care approach in dementia. Age and Ageing 35, 553–555. Higgins, J.P.T., Green, S., 2005. Systematic Reviews in Health Care: A Practical Guide. John Wiley & Sons, Chichester, USA. Hines, S., et al., 2009. Effectiveness and Appropriateness of a Palliative Approach to Care for People with Advanced Dementia: A Systematic Review. Dementia Collaborative Research Centre for Carers and Consumers, QUT, Brisbane. Hunt, D.L., McKibbon, A., 1998. Locating and appraising systematic reviews. In: Mulrow, C., Cook, D. (Eds.), Systematic Reviews: Synthesis of Best Evidence for Health Care Decisions. American College of Physicians, Philadelphia, USA, pp. 13–22. Kovach, C.R., Wilson, S.A., et al., 1996. The effects of hospice interventions on behaviors, discomfort, and physical complications of end stage dementia nursing home residents. American Journal of Alzheimer’s Disease and Other Dementias 11, 7–15. Lorenz, K.A., Lynn, J., et al., 2008. Evidence for improving palliative care at the end of life: a systematic review. Annals of Internal Medicine 148 147-W128.
