Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Abstract

Context Delivering goal-directed care is a hallmark of high-quality palliative care, but requires an understanding of preferences. Objectives To describe and identify factors associated with level of care preferences among proxies of nursing home (NH) residents with advanced dementia. Methods NH residents with advanced dementia and their proxies (N = 402 dyads) were recruited from 62 Boston-area facilities as part of an ongoing randomized clinical trial. At baseline, all proxies were asked to select which level of care they felt the resident should receive: intensive, basic, or comfort care. Multivariable logistic regression identified resident and proxy factors associated with a preference for comfort care (vs. basic or intensive medical care). Results Proxy level of care preferences were: comfort, 62.2%; basic, 31.1%; and intensive medical care, 6.5%. In multivariable analyses, proxy perception that the resident had less than six months to live was most strongly associated with a preference for comfort-focused care (adjusted odds ratio 12.25, 95% CI 4.04–37.08). Additional factors significantly associated with a preference for comfort care included older resident age, worse resident cognitive impairment, and the proxy having been asked about goals of care preferences by a NH health care provider (adjusted odds ratio 1.71, 95% CI 1.07, 2.74). Conclusion Most proxies select comfort as the preferred level of care for NH residents with advanced dementia. Discussions regarding prognosis, as well as inquiry about goals of care, are modifiable factors that may promote a preference for comfort care in this population.

Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

“…This suggests that the differences in hospitalization rates in this sample may be better explained, at least in part, by resident characteristics, such as age, functional status, and cognitive functioning, than by ACP status alone . This reflects prior research suggesting preferences for comfort‐focused care increase with advanced age and decreased cognition …”

“…6 In nursing facilities, residents and family members of incapacitated residents frequently elect to focus on comfort and avoid hospital transfers. [7][8][9] Hospital transfers are associated with negative consequences for nursing facility residents. 10 Several studies have found associations between comfort-focused goals of care and lower rates of hospitalization.…”

Outcomes of Patients With Syncope and Suspected Dementia

“…It is possible that the high rates of hospitalization were concordant with individual care preferences. However, the majority of patients with dementia and their families and/or caregivers prefer a more conservative approach to their care, making this limitation less likely . Contrarily, the reason for the limited inpatient discretionary diagnostic workup or interventions for hospitalized patients may be related to goals of care discussions and resultant goal‐concordant care, which would subsequently affect the calculated diagnostic yield of inpatient evaluation.…”

“…In addition to longer‐term adverse outcomes, patients with dementia are at increased risk for an “intervention cascade” while hospitalized. With advancing stages of dementia, an increasing majority of patients’ and their family's care preferences prioritize comfort and more conservative management that aims to limit intensive diagnostic evaluations and invasive interventions …”

A Novel Screening Method to Identify Late-Stage Dementia Patients for Palliative Care Research and Practice

“…1,2 Palliative care may benefit patients and families facing advanced-stage Alzheimer’s disease and other neurodegenerative dementias, most of whom prefer comfort-focused care. 3 These incurable and progressive diseases affect more than 5 million Americans and have extraordinary societal and family costs. 4,5 Dementia is associated with high rates of hospitalization, care transitions, and 30-day readmissions.…”