Involvement in decisions about intravenous treatment for nursing home patients: nursing homes versus hospital wards

Kristin Klomstad, Reidar Pedersen, Reidun Førde, Maria Romøren, Kristin Klomstad, Reidar Pedersen, Reidun Førde, Maria Romøren

Abstract

Background: Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient's best interest, assessment of capacity to consent, and on the patient's own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards.

Methods: Using a questionnaire, we studied the decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 (72%) patients treated in nursing homes to the 84 (28%) nursing home patients treated in the hospital.

Results: The patients' capacity to consent was considered prior to treatment in 197 (92%) of the patients treated in nursing homes and 56 (67%) of the patients treated in hospitals (p < 0.001). The answers indicate that capacity to consent can be difficult to assess. Patients that were considered capable to consent, were more often involved in the decision-making in nursing homes than in hospital (90% vs. 52%). Next of kin and other health personnel were also more rarely involved when the nursing home patient was treated in hospital. Whether advance care planning had been carried out, was more often unknown in the hospital (69% vs. 17% in nursing homes). Hospital doctors expressed more doubt about the decision to admit the patient to the hospital than about the treatment itself.

Conclusions: This study indicates a potential for improvement in decision-making processes in general, and in particular when nursing home patients are treated in a hospital ward. The findings corroborate that nursing home patients should be treated locally if adequate health care and treatment is available. The communication between the different levels of health care when hospitalization is necessary, must be better.

Trial registration: ClinicalTrials.gov NCT01023763 (12/1/09) [The registration was delayed one month after study onset due to practical reasons].

Keywords: Advance care planning; Decision making capacity; Elderly; End-of-life decisions; Ethics; Hospital; Life prolonging treatment; Next of kin; Nursing home; Patient autonomy.

Conflict of interest statement

Ethics approval and consent to participate

This study is accepted by Regional Committees for Medical and Health Research Ethics (No. 2009/1584a-1). The patients received oral and written information about the study, including the voluntariness of participation, the option to withdraw, and guarantees of full anonymity. All competent patients gave written consent, while non-competent patients’ next of kin were responsible for their consent, also in written form.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Norwegian Directorate of Health. Decision-making processes in the limitation of life-prolonging treatment. Oslo: Norwegian Directorate of Health; 2013. . Accessed 12 Apr 2018.
    1. Selbaek G, Kirkevold O, Engedal K. The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes. Int J Geriatr Psychiatr. 2007;22:843–849. doi: 10.1002/gps.1749.
    1. Causes of death, Norway. Norwegian Institute of Public Health. 2014. . Accessed 12 Apr 2018.
    1. Ramm J, editor. Health and care. Use of services among the elderly. Statistics Norway; 2013. . Accessed 12 Apr 2018. [Report in Norwegian].
    1. The Patients’ Rights Act. The Norwegian Directorate of Health. 2004. English translation: . Accessed 12 Apr 2018.
    1. Manual M. Oren Traub. Problems due to hospitalization. . Accessed 12 Apr 2018.
    1. Traub O. Problems due to hospitalization. In: The Merck manual online, Consumer Version. . Accessed 12 Apr 2018.
    1. Dreyer A, Førde R, Nortvedt P. Autonomy at the end of life: life-prolonging treatment in nursing homes-relatives’ role in the decision-making process. J Med Ethics. 2009;35:672–677. doi: 10.1136/jme.2009.030668.
    1. Dreyer A, Førde R, Nortvedt P. Life-prolonging treatment in nursing homes: how do physicians and nurses describe and justify their own practice? J Med Ethics. 2010;36:396–400. doi: 10.1136/jme.2010.036244.
    1. Gjerberg E, Førde R, Pedersen R, Bollig G. Ethical challenges in the provision of end-of-life care in Norwegian nursing homes. Soc Sci Med. 2010;71:677–684. doi: 10.1016/j.socscimed.2010.03.059.
    1. Pedersen R, Nortvedt P, Slettebø Å, Grøthe KH, Kirkevold M, Nordhaug M, Brinchmann BS, Andersen B. In quest of justice? Clinical prioritisation in health care for the aged. J Med Ethics. 2008;34:230–235. doi: 10.1136/jme.2006.018531.
    1. Fosse A, Schaufel MA, Ruths S, Malterud K. End-of-life expectations and experiences among nursing home patients and their relatives - a synthesis of qualitative studies. Patient Educ Couns. 2014;97:3–9. doi: 10.1016/j.pec.2014.05.025.
    1. Gjerberg E, Lillemoen L, Førde R, Pedersen R. End-of-life care communications and shared decision-making in Norwegian nursing homes - experiences and perspectives of patients and relatives. BMC Geriatr. 2015;15:103. doi: 10.1186/s12877-015-0096-y.
    1. Sharp T, Moran E, Kuhn I, Barclay S. Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. Br J Gen Pract. 2013;63:657–668. doi: 10.3399/bjgp13X673667.
    1. Medical Research Council. Developing and evaluating complex interventions: new guidance. 2006. . Accessed 12 Apr 2018.
    1. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–112. doi: 10.1016/j.nedt.2003.10.001.
    1. Dreyer A, Førde R, Nortvedt P. Ethical decision-making in nursing homes: influence of organizational factors. Nurs Ethics. 2011;18:514–525. doi: 10.1177/0969733011403553.
    1. Carpenter I, Gambassi G, Topinkova E, Schroll M, Finne-Soveri H, Henrard JC, et al. Community care in Europe. The aged in home care project (AdHOC) Aging Clin Exp Res. 2004;16:259–269. doi: 10.1007/BF03324550.
    1. Onder G, Carpenter I, Finne-Soveri H, Gindin J, Frijters D, Henrard JC, et al. Assessment of nursing home residents in Europe: the services and health for elderly in long TERm care (SHELTER) study. BMC Health Serv Res. 2012;12:5. doi: 10.1186/1472-6963-12-5.
    1. Tolson D, Rolland Y, Katz PR, Woo J, Morley JE, Vellas B. An international survey of nursing homes. J Am Med Dir Assoc. 2013;14:459–462. doi: 10.1016/j.jamda.2013.04.005.
    1. Froggatt K, Payne S, Morbey H, Edwards M, Finne-Soveri H, Gambassi G, et al. Palliative care development in European care homes and nursing homes: application of a typology of implementation. J Am Med Dir Assoc. 2017;18:550.e7–550.e14. doi: 10.1016/j.jamda.2017.02.016.
    1. Kjøs BØ, Havig AK. An examination of quality of care in Norwegian nursing homes - a change to more activities? Scand J Caring Sci. 2016;30:330–339. doi: 10.1111/scs.12249.
    1. Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: a systematic review. Int J Nurs Stud. 2011;48:732–750. doi: 10.1016/j.ijnurstu.2011.02.014.
    1. National Knowledgebase on quality indicators in health care. The Norwegian Directorate of eHealth. 2016. . Accessed 12 Apr 2018.
    1. Pedersen R, Hem MH, Gjerberg E, Førde R. Use of coercion in nursing homes after new legislation. Tidsskr Nor Legeforen. 2013;133:1935–1939. doi: 10.4045/tidsskr.13.0237.
    1. Førde R, Pedersen R, Nortvedt P, Aasland OG. Enough resources to the care of the elderly? Tidsskr Nor Legeforen. 2006;126:1913–1916.
    1. Office of the Auditor General of Norway. [The Office of the Auditor General’s investigation of resource utilisation and quality in the health service following the introduction of the Coordination Reform]. Document 3:5 (2015–2016), 2016. . Accessed 12 Apr 2018. [Report in Norwegian].
    1. Gjerberg E, Førde R, Bjorndal A. Staff and family relationships in end-of-life nursing home care. Nurs Ethics. 2011;18:42–53. doi: 10.1177/0969733010386160.
    1. von Hofacker S, Naalsund P, Iversen GS, Rosland JH. Emergency admissions from nursing homes to hospital at the end of life. Tidsskr nor legeforen. 2010;130:1721–1724. doi: 10.4045/tidsskr.09.1028.
    1. Romøren M, Pedersen R, Førde R. One patient, two worlds – coordination between nursing home and hospital doctors. Tidsskr nor legeforen. 2017;137:193–197. doi: 10.4045/tidsskr.16.0099.
    1. Romøren M, Pedersen R, Førde R. How do nursing home doctors involve patients and next of kin in end-of-life decisions? A qualitative study from Norway BMC Med Ethics. 2016;17:5. doi: 10.1186/s12910-016-0088-2.
    1. Romøren M, Gjelstad S, Lindbæk M. A structured training program for health workers in intravenous treatment with fluids and antibiotics in nursing homes: a modified stepped-wedge cluster-randomised trial to reduce hospital admissions. PLoS One. 2017;12:e0182619. doi: 10.1371/journal.pone.0182619.

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