ABSTRACT
Background/aims: Short-term specialized palliative homecare that is initiated timely based on complex needs has been advocated for older people with frailty. But there is insufficient evidence on the feasibility of such an intervention. To assess the feasibility and preliminary effectiveness of a timely shortterm specialized palliative homecare intervention (i.e., Frailty+) for older people with frailty and family. Methods: Pilot randomised controlled trial and process evaluation. Eligible patients were 70 years or older, had a clinical frailty score 5-7, complex needs and about to be discharged home from hospital. They were randomly assigned (1:1) to Frailty+ or standard care. The Frailty+ group received specialized palliative care by a palliative homecare nurse over 8 weeks, who followed guides for home visits. The primary endpoint was change on a sum score based on five key symptoms, i.e., breathlessness, pain, anxiety, constipation, drowsiness, over 8 weeks. Feasibility, implementation, mechanisms and context were assessed post-intervention using mixed methods. We used thematic and descriptive statistical analyses. Results: 37 patients were randomly assigned to Frailty+ group (n=19, mean age 84y) or standard care (n=18, mean age 84y) and 26 family carers. The Frailty+ group received at least one home visit, as intended. Hospital care staff reported difficulties in patient identification. Patients and family reported positive views on the home visits, nurses that the guides were often not useful. Most important contextual factors were related to the COVID-19 crisis e.g., less continuity of care. Mean sum scores on primary outcome at baseline was 6.0 in Frailty+ and 5.6 in the control group, at 8-weeks was 4.5 in Frailty+ and 4.1 in the control group (adjusted ratio 1.0). Conclusions: Frailty+ was well received by patients and family and to a lesser extent healthcare providers. Based on these results, further refinement of Frailty+ and RCT design is needed to optimize the intervention and evaluation.
ABSTRACT
Background: COVID-19 mortality disproportionally affects nursing homes, creating enormous pressures to deliver high-quality end-of-life care. Comprehensive palliative care should be an explicit part of both national and global COVID- 19 response plans. Aims: To identify, review and compare national and international COVID-19 guidance for nursing homes concerning palliative care, issued by government bodies and professional associations in low-, middle-, and high-income countries. Methods: We performed a directed documentary and content analysis of newly developed or adapted COVID-19 guidance documents from across the world. Documents were collected via expert consultation and independently screened against prespecified eligibility criteria. We applied thematic analysis and narrative synthesis techniques. Results: We identified 21 eligible documents covering both nursing homes and palliative care;from the World Health Organisation (n = 3), and 8 individual countries: United States (n = 6), Canada (n = 1), the Netherlands (n = 2), Ireland (n = 1), United Kingdom (n = 3), Switzerland (n = 3), New Zealand (n = 1), Belgium (n = 1). International documents focused primarily on infection prevention and control, including only a few sentences on palliative-care-related topics. Palliative care themes most frequently mentioned across documents were end-of-life visits, advance care planning documentation, and clinical decision- making towards the end of life (focusing on hospital transfers). Conclusion: There is a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. Most have a limited focus both regarding breadth of topics and recommendations made. Key aspects of palliative care, that is, symptom management, staff education and support, referral to specialist services or hospice, and family support, need greater attention in future guidelines.