Keywords: palliative care, nursing homes, frailty condition, shared care plan

Background:

Only a small number of elderly residents in nursing homes (NHs) currently receive early palliative care (PC) raising the issue of increasing awareness about terminality and the PC options in patients, caregivers and healthcare professionals.

Research questions:

Identify patients who may require palliative care in the next 12 months and assess recognition of this need among GPs, patients and caregivers.

Method:

The NECPAL questionnaire was applied to 198 patients of 10 GPs in Ulss 9 Scaligera (Veneto Region) over 2 months. Patients resulted NECPAL POSITIVE or NEGATIVE based respectively on their NO or YES response to the surprise question. The perception of the need for PC by patients, family members and GPs was analysed. The characteristics of frailty and clinical progression of the patients' disease were collected.

Results:

28.8% patients resulted NECPAL positive, 67.2% NECPAL negative and 4% uncertain. The request/need for PC from the patient or caregivers occurred in 7.6%. The request for limitation of therapeutic effort/refusal of treatment in 14.8%. The need for a palliative approach was confirmed by GPs in 11.1%. The patients (32.8% M, 67.2% F) were aged over 75 in 89.9%. General Clinical Indicators of Severity and Progression: nutritional markers (31%); functional markers (44.4%); frailty/gravity markers (62%); emotive stress/psychological symptoms (42.4%); clinical complexity 33.8%); comorbidity (97.5%). Prevalence of Disease Specific Clinical Indicators: Dementia (47.5%), Chronic heart disease (26.8%), Neurodegenerative diseases (23.7%), Cerebrovascular diseases (10.6%), Chronic pulmonary disease (10.1%), Cancer (6.6%), Renal failure (5.6%), Liver disease (2%).

Conclusions:

In approximately one third of cases, a terminal condition was detected, only partially corresponding to the awareness of this need of PC among GPs, patients or family members. The population assisted at NHs is characterized by advanced age, high clinical complexity and frailty, confirming a high probability of necessity of palliative care/approach, likely major than what detected.

Points for discussion:

Identifying terminality is the first step towards addressing the need for a palliative approach and a shared care planning (SCP): how to build those pathways?

How can healthcare professionals in nursing homes incorporate the use of the questionnaire into their organization?

The whole population should have access to palliative care, how to tackle this necessity?