Life In The Slower Lane

Here is the structured PICO analysis for the fifty-seventh article you uploaded:

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Full Title (verbatim and exact):

“Changes in Care Goals and Treatment Orders Around the Occurrence of Health Problems and Hospital Transfers in Dementia: A Prospective Study”

Hendriks SA, Smalbrugge M, Hertogh CMPM, van der Steen JT

Journal of the American Geriatrics Society (2017); 65:769–776

DOI: 10.1111/jgs.14667

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Type of Article:

Prospective longitudinal observational study (part of the Dutch End of Life in Dementia study)

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PICO Analysis:

Population:

• 372 newly admitted nursing home residents with dementia from 28 Dutch long-term care facilities
• Followed for up to 3.5 years
• Mean age at admission: 84 years; 70% female
• Participants were in various stages of dementia; 9% had advanced dementia at baseline 

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Intervention (Observed Exposure):

• Advance care planning (ACP) processes, specifically:
  • Changes in care goals (e.g., life prolongation, preserving function, palliative goals)
  • Documentation of treatment orders (e.g., do-not-hospitalise, do-not-resuscitate, do-not-intubate)
• Changes were observed in relation to health deterioration events such as pneumonia or intake problems (e.g., swallowing difficulties)

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Comparator:

• Comparison of care goals and treatment orders before and after the occurrence of health problems (pneumonia or intake problems)
• Also compared patients who developed these issues vs those who did not

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Outcome:

1. Person-centred outcomes:

• Indirectly observed through changes in:
  • Care goals: shift from life-prolonging to palliative care as dementia progressed
  • Alignment of hospitalisation decisions with pre-documented care goals
• By the time of death:
  • 90% had palliative care goals
  • 92% had do-not-resuscitate orders
  • 76% had do-not-hospitalise orders 

2. Process outcomes:

• Care goals were discussed with proxies in 80% of residents within 8 weeks of admission
• Most frequent treatment orders addressed:
  • Resuscitation
  • Hospitalisation
  • Intubation
  • Antibiotic therapy
• Proportion with do-not-hospitalise orders:
  • 28% at baseline
  • 76% in the last 6 months of life
• Pneumonia alone did not trigger major care goal changes, but intake problems did (e.g., increased documentation of palliative goals and do-not-treat orders) 

3. Health system outcomes:

• Hospitalisation rate was low: 12% within first year after admission
• Hospitalisation occurred despite a do-not-hospitalise order in 21% of cases
  • Most common reason: hip fracture (43% of hospitalisations)
• Suggests possible overrule of prior preferences for emergency surgical indications 

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Summary Conclusion:

This Dutch longitudinal study found that most residents with dementia in long-term care had palliative care goals documented shortly after admission, and these goals generally became more specific (e.g., do-not-hospitalise) as the resident’s condition worsened. Intake problems were more likely than pneumonia to prompt updates in care plans. Although hospital transfers were rare, they still occurred in 1 in 5 cases despite a do-not-hospitalise order, especially for fractures requiring surgery. The study underscores the importance of early and ongoing ACP, tailored to specific health decline triggers, and highlights how even clear documentation may not fully prevent burdensome interventions unless systems for aligning care decisions with goals are robust.

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