Browsing School, Graduate by Subject "Palliative Care"
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End-of-Life Care in U.S. Nursing Homes: Resident and Facility Factors that Predict Presence and Use of ServicesResearch has demonstrated the benefits of nursing homes offering specialized end-of-life services for their residents. These benefits include improved symptom management and emotional support. Prior research has identified, however, that referrals and use of these specialized end-of-life services for nursing home residents is still quite minimal, leaving significant unmet needs for these individuals in their last days of life. The purpose of this study was to explore the resident and organizational factors that may serve as catalysts and barriers to providing quality end-of-life care in U.S. nursing homes. This study is a cross-sectional design utilizing secondary data from the 2004 National Nursing Home Survey. A logistic regression analysis and multi-level regression analyses were performed to explore predictors for the presence and use of end-of-life services in these facilities. There were several facility variables that predicted the presence of end-of-life services in the facilities. Facilities that were for-profit, larger in size, and participated in end-of-life planning initiatives were more likely to offer end-of-life services. Facility geographic location was also a predictor with those nursing homes located in the West being less likely to offer end-of-life services. Factors specific to the nursing home resident that predicted utilization of end-of-life services included older age, decreased bed mobility, reports of pain, indicators of emotional distress (depression, sadness, or anxiety), and specific diagnoses (neoplasms and respiratory diseases). Having an advanced directive in place also increased the resident's odds of utilizing EOL services. Residents with primary payment sources of Medicare and Medicaid were found to be less likely to utilize services. With one-fifth of the deaths in the United States occurring in nursing home facilities, it is essential to ensure that quality end-of-life programs are in place to address the needs of the residents. Understanding the potential barriers for both the nursing home in implementing programs and the resident in accessing the services is essential in developing strategies for policies and procedures for quality end-of-life care.
New treatment targets in heart failure: Patient reported outcome measures and subjective well-beingBackground: Despite costly advances in heart failure management, heart failure is characterized by pervasive adverse and complex symptoms, functional decline, and poor quality of life. A robust theoretical framework comprehending provider and patient paradigms guided this study seeking new treatment targets to augment existing advanced therapies. Aims: The aim of this study is to examine subjective well-being associations with other patient reported outcome measures, and disease and treatment outcomes, in individuals with heart failure. Methods: This cross sectional, correlational study used data collected from 88 individuals undergoing inpatient heart failure treatment in a large urban academic medical center (50% male, average age 67±6. 9, median duration of heart failure >4 years, mean vEF =32%). Following consent, patients completed a 30 minute interview consisting of valid, reliable ‘patient reported outcome measures’ of subjective well-being, symptom burden, intrusion of illness and treatment in meaningful life pursuits, and health related quality of life. Disease, treatment and social characteristics were abstracted from medical records. Data analyses were conducted using correlation, non parametric statistics and regression models. Results: ‘Patient reported outcome measures’ had good internal reliability (Cronbach’s alpha >.8). Subjective well-being scores detected differences based on age, functional, employment and insurance statuses. Health related quality of life and subjective well-being measures correlated with illness intrusiveness (.53, -.40). The most prevalent symptoms reported (75-97%), were xerostomia, dyspnea, fatigue, pain, worry and sleep disruption. In multiple regression models, illness intrusiveness predicted subjective well-being (R2 change=.29, p≤.01) health related quality of life (R2 change= .24, p≤.01), after controlling for functional and insurance statuses. Conclusion: ‘Patient reported outcome measures’ including subjective well-being scales contribute unique findings to inform individualized heart failure treatment. New heart failure treatment targets identified in this sample include multidimensional symptom management, functional support, prognostication and advance care planning, all components of primary palliative care.