Nursing staff participation in end‐of‐life nutrition and hydration decision‐making in a nursing home: A qualitative study

Abstract

Aim: To better understand the participation of nursing staff in end-of-life nutrition and hydration decision-making in an American nursing home. Design: A qualitative exploration with ethnographic focus. Methods: In April 2017, in-person, semi-structured interviews were performed with 19 nursing staff members in a nursing home located in the southeastern United States. Additional information was gathered through participant observation during interviews and review of organizational and regulatory policies. Transcripts were coded and analysed using qualitative methods described by Roper and Shapira (2000). Results: Three primary themes relating to nursing staff participation in end-of-life nutrition and hydration decision-making were identified: (a) Formal decision-making: decisions made and implemented by persons with the authority to make legal and binding care decisions in the nursing home setting; (b) Informal decision-making: decisions not requiring medical orders; and (c) Influential factors: factors that influence actions of nursing staff. Conclusion: A variety of factors have an impact on nursing staff participation in endof-life nutrition and hydration decision-making. Participation is closely aligned with the type of decision, whether formal or informal, and role, whether Certified Nursing Assistant/Aide, Licensed Practical/Vocational Nurse, or Registered Nurse. Impact: End-of-life nutrition and hydration decision-making in nursing homes differs from decision-making in other care settings and presents a challenge globally. Interventions that support the participation of nursing staff in end-of-life nutrition and hydration decision-making have the potential to positively impact the experiences of residents and family members faced with these issues in the nursing home setting.

Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review

“…Since the roles of most HCPs are not well defined in the EOL nutrition context, it remains unclear who provides support and assistance or where families can seek information about EOL nutrition care. Nurses are highlighted throughout the literature as a key human resource whose proximity to families and other HCPs leads to naturally occurring opportunities for conversations about care [ 64 , 65 ]. Since nursing care is fundamental for supporting vital nutritional needs when challenges arise with a patient’s natural oral intake of food, nurses hold the unique position of “skilled companion” for patients and families, which predisposes them to opportunities for building relationships and leading multidisciplinary conversations about a patient’s care [ 65 ].…”

“…Some of the studies indicated that physicians and physician assistants may assume responsibility for facilitating EOL care decisions. Without defined roles, there remains hesitation and challenges in supporting families with EOL decision-making, particularly when family conflicts arise [ 13 , 64 , 66 ]. Further complicating the situation is that HCPs hold differing perspectives as to the benefits of ANH or how to engage families in decision-making around EOL nutrition [ 16 , 59 ].…”

Reasons for and against Nutritional Interventions. An Exploration in the Nursing Home Setting

“…In addition, we considered low food intake, an important aetiological sign of MN, known as a strong predictor of six-month mortality [ 23 ]. Each of these three objective criteria may indicate malnutrition and justify NIs, but does not necessarily have to lead to these measures, e.g., in an end-of-life situation [ 24 , 25 ]. The selection of these criteria is also based on the results of the “Malnutrition in the elderly” Knowledge Hub.…”

Lived experiences of end‐of‐life communication among nursing home staff: An interpretive phenomenological study

“…However, end‐of‐life communication is not always practiced or is delayed until a resident's health deteriorates (Evenblij et al, 2019). This delay is often justified by fluctuating disease trajectories and a lack of predictive certainty, which add complexity to end‐of‐life care decisions (Evenblij et al, 2019; Firnhaber et al, 2020). However, the literature also highlights a wide array of staff‐related barriers to end‐of‐life communication that may be anticipated and addressed, including lack of training and multidisciplinary collaboration, uncertainty about prognostication, time pressure, emotional discomfort, lack of confidence, feeling unprepared to initiate and sustain such conversations, and fear of a negative impact on residents (De Vleminck et al, 2014; Furman et al, 2007; Travers & Taylor, 2016; Young et al, 2017).…”