End-of-life in the nursing home – doctor’s challenges, prescriptions and initiatives.

Project Department: Uni Research Health (group: Research Unit for General Practice in Bergen) period: from 01.05.12

Project results

  • Palliative medication was prescribed to 74% of patients on the day of death. Most drug changes occurred on the day of death.
  • Anticholinergic treatment of death rattle is not more effective than placebo. Morphine and midazolam for breathlessness, anxiety and restlessness /agitation has some evidence.

  • The existential vulnerability of nursing home doctors, the vulnerability of being reminded of one’s mortality, may be of benefit both to the dialogue with patient and family, as well as for professional coping.

 

About the project

Nearly half of all deaths in Norway occur in nursing homes. What is the doctor’s role in patient care at the end-of-life in nursing homes? Our project focuses three aspects:

  • Drug prescribing near the end of life
  • Evidence base for palliative drug treatment  
  • Challenges experienced by doctors working with dying nursing home patients                

 

Palliative medication

A cohort study among deceased nursing home patients showed that palliative medication was prescribed to 74% of patients on the day of death; especially for cancer patients and patients with long stays. Most drug changes occurred on the day of death.

 

Evidence-based drug treatment

A systematic review of the effectiveness (symptom control) and safety (side effects and survival) of palliative drug treatment of dying adult patients identified 5940 unique titles, from which 12 studies were included. Five studies assessed anticholinergics for death rattle, providing no evidence that scopolamine hydrobromide or atropine were superior to placebo. Five studies examined drugs for dyspnea, anxiety, or terminal restlessness, providing some evidence supporting the use of morphine and midazolam. Two studies examined opioids for pain, providing some support for morphine, diamorphine and fentanyl. Eight studies included safety outcomes, revealing no important differences in adverse effects between the interventions, and no evidence for midazolam shortening survival.

 

Doctors’ challenges

Focus group interviews exploring nursing home doctors' experiences with dying patients found that existential vulnerability, the vulnerability of being reminded of one’s mortality, is experienced as a burden of powerlessness and guilt in difficult treatment compromises and in the need for protective disengagement, but also as a resource in communication and professional coping.

 

Project period: 01.05.12 - 31.12.17

Funding: General Practice Research Fund

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cp: 2017-12-14 09:18:11