Implementation of Knowledge-Based Palliative Care for Frail Older Persons in Nursing Homes

The number of nursing home beds has decreased the last five years in spite of increased average lifespan in the Swedish population. The result is that the persons living in nursing homes in Sweden today are increasingly frail and suffering from multiple morbidities. This is apparent as up to 40 % of all deaths occur in nursing homes (The Swedish Register of Palliative Care, 2013) while at the same time, older people and people with chronic diseases has proved to be particularly disadvantaged in terms of palliative care (Socialstyrelsen, 2004). Both the National Board of Health and Welfare and the World Health Organization advocates that everyone that needs palliative care should have access to it regardless of age.

Dying among older persons is often a prolonged period of time which means that it is difficult to identify when the final stages of life begins for older persons and thus when to provide palliative care. It has also been shown that the availability of palliative care is unequal across Sweden (Socialstyrelsen, 2006). The National Board of Health (Socialstyrelsen, 2013) has, because of the unequal availability of palliative care in Sweden, been commissioned to draw up a national knowledgebase that focuses on proper palliative care. Two documents have been produced in order to provide support for developing, implementing and following up knowledge-based palliative care for persons in their final stages of life: A national care program by the Regional Co-operative Cancer Centers (Regionala cancercentrum i samverkan 2012) and a national knowledge support document by the National Board of Health and Welfare (Socialstyrelsen 2013).

The purpose of this project is to:

A) Implement and evaluate how a knowledge-based model for palliative care in nursing homes affects the quality of life and the participation in the care process for older persons in nursing homes and their next of kin.

B) Explore the staff’s implementation process of palliative care and the role of the leadership.

C) To investigate which factors that affects the implementation process of this model.

The project is conducted as a cross-over implementation study in two counties (Kronoberg and Skåne) in the south of Sweden and is based on an education intervention through workshops and coaching sessions for professionals in nursing homes. Every group meets once a month and include different professions (unit manager, district nurse, assistant nurse, and other staff i.e. occupational therapist and physiotherapist). There will be 5 meetings with about 8-10 participants in each group from each nursing home. The educational material consist of six themes; values in palliative care, symptom relief, dignity and a dignified death, collaborative co-creating care, support to next of kin and dialogue with older persons and next of kin about death and dying. The content of the different themes will have a common core for each nursing home but will be adjusted based on the expressed needs of each nursing home. The participants in the workshop will reflect together over the content of the developed binder of educational material and will relate it to their own work in order to identify areas suitable for changes and/or development. The main tailored intervention study and data collection is ongoing under 9 months in each county during 2015-2017 and is based on previous pilot studies. Twenty nursing homes participate as intervention nursing homes and an equal number of nursing homes participate as a control group. Data collection will be finished in May 2017.

The project is the first implementation research project which takes the national knowledge based documents on palliative care into practise. The result contributes with scientific knowledge about the outcomes, barriers and facilitators, for the implementation of a knowledge-based palliative care in nursing home. The education strategies used to implement palliative care of high quality can serve as a model for other nursing homes. This project also explores the importance of nursing home leadership and culture for the implementation of palliative care.