Life In The Slower Lane

Here is the standardised PICO analysis for the sixty-third uploaded article:

---

Full Title

Experiences and Involvement of Family Members in Transfer Decisions from Nursing Home to Hospital: A Systematic Review of Qualitative Research

Authors: Alexandra Pulst, Alexander M. Fassmer, Guido Schmiemann

Journal: BMC Geriatrics, 2019; 19:155

DOI: 10.1186/s12877-019-1170-7

---

Type of Study

Systematic review of qualitative studies, using meta-aggregation

---

PICO Summary

Population (P)

• Family members (including children, spouses, and informal caregivers) of nursing home residents (NHRs)
• Residents were typically older, frail, and living in long-term residential aged care settings
• Ten studies were included (USA, Canada, Australia, Norway, Netherlands), covering perspectives on hospital transfer and end-of-life decision-making 

Intervention (I)

• Family involvement in decision-making regarding hospital transfer and end-of-life care
• Focused on:
  • Treatment discussions (e.g. DNR/DNH orders, ACP)
  • Reactions to acute medical changes
  • Roles in advocating for or against hospital transfer

Comparison (C)

• Not applicable (qualitative synthesis)
• Comparisons made across different themes and degrees of family involvement

Outcomes (O)

Synthesised findings across five domains (see Figure 2 on page 8 for thematic map):

1. Nursing home-related factors
   • Family members cited understaffing, inadequate staff training, and lack of on-site physicians as justifications for hospital transfer
   • Conversely, trust in NH staff and perception of compassionate, personalised care led to preference for in-place care 
2. Hospital-related factors
   • Families valued quick diagnostics, 24/7 care, and superior equipment in hospitals
   • However, they also reported trauma, disorientation (especially for dementia), and lack of dignity or privacy in EDs, reducing hospital preference 
3. Resident- and family-related factors
   • Transfer more likely during perceived acute deterioration or ambiguous symptom severity
   • End-of-life symptoms often misunderstood; advance directives rarely definitive
   • Relatives sometimes overrode or misunderstood resident preferences, driven by emotional stress or guilt 
4. Communication and decision-making dynamics
   • Engagement ranged from no involvement to full control
   • Family members appreciated staff recommendations but also reported conflicts over best interest judgments and discomfort during ACP discussions
   • Some deferred to medical authority; others pushed for hospitalization despite DNH orders 
5. Relatives as information bridges
   • Families helped “fill in the gaps” in communication between NH and hospital staff
   • Especially valued when residents had dementia or communication barriers 

---

Conclusion

This review reveals that family involvement in hospital transfer decisions is highly variable and deeply influenced by:

• Perceptions of care quality in NHs and hospitals
• Relational trust with staff
• Understanding (or misunderstanding) of resident wishes
• Emotional readiness to confront end-of-life

Despite the distress, families play a critical role in decision-making and communication continuity. Interventions to reduce unnecessary hospitalisation must include structured support and guidance for families, especially around ACP, emotional preparation, and collaborative care planning.

---