Susan E. Hickman

High-intensity environmental light in dementia: Effect on sleep and activity

OBJECTIVES: To determine whether high‐intensity ambient light in public areas of long‐term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia.

The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form

To evaluate the consistency between treatments provided and Physician Orders for Life‐Sustaining Treatment (POLST) orders.

Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting.

BACKGROUND The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting. OBJECTIVE To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients. DESIGN A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2). RESULTS The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization. CONCLUSIONS The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.

The Effect of Ambient Bright Light Therapy on Depressive Symptoms in Persons with Dementia

OBJECTIVES: To assess the effect of ambient bright light therapy on depressive symptoms in persons with dementia.

Impact of ambient bright light on agitation in dementia

To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia.

Sampling challenges in end-of-life research: Case-finding for family informants

BackgroundResearch on end-of-life care is hampered by challenges in accessing appropriate subjects for data collection. Although families of decedents are rich sources of research data, they are underutilized, most likely due to the access difficulties they present to investigators. ObjectivesTo describe case-finding strategies that can achieve a large and representative sample of family informants for research studies about end-of-life care. MethodsCase-finding strategies were developed and honed over the course of three epidemiological studies on end-of-life care. Family location information was culled from death certificates and a combination of public and commercial sources. ResultsThe researchers generated large random samples of study-eligible decedents and, using the case-finding strategies described, recruited family members of decedents as informants. By the third study, two-thirds of family members were located and interviewed within the narrow time frame of 2–5 months following the death of their loved one. DiscussionEpidemiological studies on end-of-life, using large random samples of decedents and their family members, are feasible when armed with an array of effective case finding strategies.

Trends in Opioid Use over Time: 1997 to 1999

Substantial resources have been spent to improve pain control for dying patients, and increased opioid administration has been presumed. Oregon has been a consistent leading state in per capita use for morphine for the past 10 years, as recorded by the Automation of Reports and Consolidated Orders System (ARCOS). Health policy experts, extrapolating from World Health Organization methods, have suggested these data are indicative of the quality of end-of-life care in Oregon. To determine whether trends in opioid prescription at the state and national levels reflect increased opioid use for inpatients during the final week of life, chart reviews were conducted to record all opioid medications administered in the last week of life to 877 adult inpatients who died from natural causes between January 1, 1997 and December 31, 1999. Inpatient morphine use did not increase significantly for dying patients from 1997 to 1999. However, overall morphine use for both Oregon and the United States as measured by ARCOS data increased significantly. Comparisons revealed no significant difference between linear trends for Oregon and U.S. morphine use, but both were significantly greater than the dying inpatients. This pattern was also found for all other opioids. These findings suggest that ARCOS data do not necessarily provide information about opioid use for specific subpopulations of patients and raise questions about the meaning of observed increases in ARCOS data.

Nursing Home Participation in End-of-Life Programs: United States, 2004:

The purpose of this report is to define the extent to which US nursing homes (NH) participate in end-of-life programs, using a nationally representative, cross-sectional sample of US NH. Data on EoL programs including Five Wishes, Last Acts, and Physician Orders for Life-Sustaining Treatment (POLST) were collected. In 2004, 17.2% of NH reported participating in 1 or more of these programs, with the largest proportion participating in POLST (13.3%) and smaller proportions in Five Wishes (5.6%) and Last Acts (4.2%). Nursing homes were more likely to participate in EoL programs if they also offered specialty programs and staff training for hospice, end-of-life, pain management, and dementia services. In 2004, fewer than 1 in 5 US NH participated in an EoL program. However, facilities that had EoL programs were more likely to have programs and staff training for services related to EoL care, a finding that suggests a clustering of these programs, services, and training. Provision of appropriate staff training may be a key to expanding EoL program participation in skilled nursing.

Navigating federalwide assurance requirements when conducting research in community-based care settings.

There is an urgent need for research on quality of life and healthcare delivery for older adults living in community‐based care settings, yet implementing current federalwide assurance (FWA) requirements can be a challenge in these settings. This paper discusses FWA requirements for engagement in federally funded research as the requirements pertain to community‐based care settings. Factors that impede community facilities in achieving FWA approval include lack of organizational structure to provide oversight for the ethical conduct of research, administrator concerns regarding potential liability associated with obtaining the FWA, lack of resources to complete required paperwork, and lack of staff knowledge about human subjects protection and federal requirements for participating in research. Effects of the FWA process on investigators include the burden of extra time needed to support community‐based facilities to acquire a FWA and concerns that studies may be limited to only those community facilities with the resources to complete the FWA process. Investigator‐initiated strategies for conducting research in community‐based settings include considering study designs that are exempt from the FWA process and proactively assisting community‐based facilities to acquire FWA status. Investigators need to work with potential research sites and the office for human research protections to ensure that subjects are protected without shifting the burden of protection to ill‐prepared community administrators.