Delivering palliative care in long-term care facilities: how can we get it right?

Patients who reside in long-term care (LTC) facilities, including care and nursing homes, commonly are frail with extensive multi-morbidity.¹ There has been a recent focus upon delivering palliative care within the LTC environment due to the Covid-19 pandemic,² and for the right patient in the right scenario this can be of significant benefit. Indeed, for some the transfer to hospital from LTC facilities at the end of life can be associated with unwanted interventions and distress without significant improvements in symptomatic support.³

LTC facilities in the UK have been working hard to achieve this for some time, with Covid-19 placing them under even more pressure. The Office for National Statistics reported that 72.2% of deaths in care home residents secondary to Covid-19 occurred within the LTC environment.⁴

The significant increase in palliative care discussions with patients and families over the past  two months has prompted personal reflections upon clinical scenarios where palliative care discussions and management have gone well for patients residing in LTC facilities. Case vignettes based on real scenarios have been used to highlight themes that have proved to be helpful in our locality.

Accessibility of broader medical support for LTC Staff

James was a 97-year old frail gentleman with end stage dementia who developed Covid-19, and unfortunately rapidly deteriorated with the course of an afternoon requiring medical review by his GP. On arrival at the nursing home, he was hypoxic at 85%, tachypneic at 30 respirations per minute and pyrexial at 40C. Most importantly he was distressed.

Working with the Hospital @ Home and palliative care team, rapid symptom relief was started (including oxygen, morphine and midazolam) leading to significant reduction in patient distress. Such rapid response care teams can lead to significant improvement in the delivery of palliative care, by reducing delays in commencing treatment and associated anxiety of LTC staff, patient and relatives.⁵

Basic understanding of prognosis and disease trajectory

Diana is a 69-year old with severe interstitial pulmonary fibrosis with rapidly decreasing respiratory functioning. Initially reluctant to discuss €˜dying’ despite recent admission to a nursing home, after a severe chest infection Diana wished to have discussions about €˜what the future hold for me’. A meeting with her own GP, respiratory specialist nurse and palliative care nurse was arranged to discuss her worries and her likely prognosis. This helped her make informed decisions with her family about her anticipatory care plan.

Communication with patients, family and LTC staff

Angela is an 89-year old lady who has had five admissions to hospital in the last four months. She has significant cardiac and respiratory diagnoses. During her last admission the consultant geriatrician engaged the patient and her family explaining that Angela was likely in the latter stages of her life. Angela and her family agreed that admission to hospital in future should be avoided, and that focus should be on her symptoms and several non-essential medications were held.

The geriatric medicine team worked with the LTC facility and her GP to have a clear management plan for her heart failure and her care plan was updated. She remained comfortable for some weeks before she passed away surrounded by her family.

Documentation of relevant anticipatory care discussions

Charles was a 94-year old gentleman with metastatic lung cancer, and severe congestive cardiac failure. His GP had engaged with the family and patient about end of life care shortly after his diagnosis of lung cancer, and a do not resuscitate form was put in place alongside as required medications (including morphine and midazolam).

These discussions were recorded in medical notes and printed into his care plan at the home, and were shared with ambulance and out of hours service. He remained stable and comfortable for some weeks after his diagnosis, but suddenly deteriorated. When he deteriorated, the out of hours GP and agency nurse on duty were able to implement his palliative care plan. He passed away overnight with his family in attendance.

Conclusion

There can be significant challenges in delivering palliative care to some LTC residents. A recent paper commented that inherent unpredictability in some patients decline, poor communication sharing and difficulty in accessing prompt out of hour access to medical support for palliative patients often hamper efforts to deliver palliative care in patient homes.³ Hopefully, future research will build upon best practice to promote accessibility of medical support for community palliative care, communication between all interested parties and documentation and dissemination of end of life discussions. Covid-19 has shown that LTC staff are eager to provide quality palliative care for their patients but they need more support.

Lloyd Hughes, GP, NHS Fife

References

1. Reilev M, Lundby C, Jensen J, Larsen SP, Hoffmann H, PottegÃ¥rd A. Morbidity and mortality among older people admitted to nursing home. 2019. Age Ageing. 49(1):67€73.
2. Hermans, S., Sevenants, A., Declercq, A., Van Broeck, N., Deliens, L., Cohen, J. and Van Audenhove, C., 2019. Integrated Palliative Care for Nursing Home Residents: Exploring the Challenges in the Collaboration between Nursing Homes, Home Care and Hospitals. International Journal of Integrated Care, 19(2), p.3.
3. Alcorn G, Murray SA & Hockley J. Care home residents who die in hospital: exploring factors, processes and experiences. 2020. Age and Ageing, 49 (3), 468€“480
4. Office for National Statistics. Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 1 May 2020 and registered up to 9 May 2020 (provisional). London, 2020. Last Accessed 3rd June 2020.
5. Grannon N, McKenna E P-200 Triage and rapid response in palliative care: does it make a difference? BMJ Supportive & Palliative Care 2017;7:A81.