McGlade Ciara, Daly Edel, McCarthy Joan, Cornally Nicola, Weathers Elizabeth, O'Caoimh Rónán, Molloy D William
University College Cork, Ireland.
Nurs Ethics. 2017 Feb;24(1):87-99. doi: 10.1177/0969733016664969. Epub 2016 Sep 22.
A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the 'Let Me Decide' advance care planning programme in long-term-care.
This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval.
Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training.
The challenges encountered were largely concerned with preserving resident's autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources.
Although it may be too late for many long-term-care residents to complete their own advance care directive, the ' Let Me Decide' programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.
认知障碍和身体虚弱的高患病率使长期护理人群中预先护理计划的可行性变得复杂。研究目的：确定在长期护理中实施“让我决定”预先护理计划项目所面临的挑战。
这项可行性研究有两个阶段：（1）对工作人员进行预先护理计划方面的教育；（2）工作人员与居民及其家属进行结构化的预先护理计划。参与者和研究背景：两家养老院和一家社区医院的长期护理居民。伦理考量：当地研究伦理委员会给予了伦理批准。
实施后，超过50%的居民完成了某种形式的临终护理计划。在实施后阶段死亡的70名居民中，14%没有护理计划，10%（有行为能力）完成了预先医疗指示，而缺乏行为能力的居民中，76%在与居民（如果可能）和家属讨论后，由医疗团队为他们完成了临终护理计划。让工作人员脱产参加培训面临着巨大的后勤挑战，这促使开发了一个电子学习项目以促进培训。
所遇到的挑战主要涉及维护居民的自主权、避免伤害和次优或危机决策，以及通过优化有限资源确保居民得到公平对待。
尽管对于许多长期护理居民来说，完成他们自己的预先医疗指示可能为时已晚，但“让我决定”项目为不同能力完成预先医疗指示的居民提供了一种可行且可接受的结构化临终护理计划选项，包括与居民（在其能力范围内）及其家属进行讨论。虽然提供临终护理计划很耗时，但一旦在实践中改善沟通和增强所有相关方内心平静的好处显现出来，护理人员愿意克服这一困难并承担该项目。
