Life In The Slower Lane

Here is the PICO analysis for the seventh uploaded article:

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✅ PICO Analysis

Full Article Title:

Preventing Burdensome Transitions of Nursing Home Residents with Advanced Dementia: It’s More than Advance Directives

Type of Study:

Qualitative descriptive study using semistructured interviews

Journal and Year:

Journal of Palliative Medicine (2017); 20(11):1205–1209

DOI: 10.1089/jpm.2017.0050

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P – Population

• Setting: Nine nursing homes (NHs) within 60 miles of Boston, USA
• Participants:
  • 20 healthcare professionals (14 nurses, 6 physicians) involved in care of residents with advanced dementia
  • Nursing home sizes ranged from 50 to 200 beds
• Resident Context:
  • Advanced dementia (Global Deterioration Scale score of 7)
  • NH residents aged ≥60, reliant on others for all activities of daily living, at high risk of death and burdensome interventions 

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I – Intervention (or Exposure)

• Nature of Exposure:
  • The study examines how decisions are made to hospitalise residents with advanced dementia, not a specific clinical intervention
  • Key “interventions” or factors influencing decision-making include:
    • Early “groundwork” conversations with surrogate decision-makers
    • Use of DNH (Do Not Hospitalize) orders
    • Providers’ ability to:
      • Establish trust
      • Foreshadow the illness trajectory
      • Discuss the risks of hospitalization
    • Real-time decision-making during acute events

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C – Comparison

• No formal control group.
• Implicit comparison between:
  • Cases where groundwork was effectively laid vs. where it was not
  • Facilities/providers with strong internal capacity for palliative care vs. those without

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O – Outcomes

Key Thematic Outcomes:

1. Decision-Making Process:
   • Two-phase model:
     • Phase 1: Laying the groundwork—focused on establishing trust, setting expectations, and obtaining advance directives (e.g., DNH orders)
     • Phase 2: Responding to acute events—requiring capacity for in-house management, provider confidence, and ongoing family negotiation
2. Influencing Factors:
   • Trust between staff and surrogates was essential to avoiding hospital transfer
   • Even with advance directives in place, families often made final decisions during acute events
   • Nurses and physicians recognised their own influence (positive or negative) in guiding decisions
   • Availability of diagnostics, treatments, and palliative care in the NH enabled in-place care
3. Conclusion:
   • Advance care planning alone is insufficient; timely, skilled, real-time clinical engagement is essential
   • Preventing burdensome transfers depends on both structural NH capabilities and the quality of human interactions with surrogates at each crisis point 

Outcome Classification:

• Person-centred outcomes: Respect for goals of care, reduced hospital transfers, better end-of-life experience for residents and families
• Process outcomes: Improved surrogate-provider communication, staff confidence in palliative discussions
• System outcomes: Reduced potentially avoidable hospitalisations (implied)

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