VUB-UGhent End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Brussel, Belgium.
Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussel, Belgium.
JAMA Intern Med. 2020 Feb 1;180(2):233-242. doi: 10.1001/jamainternmed.2019.5349.
High-quality evidence on how to improve palliative care in nursing homes is lacking.
To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes.
DESIGN, SETTING, AND PARTICIPANTS: A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio.
The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death.
The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1).
Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents' comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, -0.55; 95% CI, -1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018.
Residents' comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important.
ISRCTN Identifier: ISRCTN14741671.
缺乏关于如何改善养老院姑息治疗的高质量证据。
调查 PACE 成功计划（PACE Steps to Success Program）对居民和员工结果的影响。
设计、设置和参与者：一项在 7 个国家的 78 家养老院进行的群组随机临床试验（2015-2017 年），将 PACE Steps to Success Program（干预组）与常规护理（对照组）进行比较。随机化按国家和每个国家的中位数床位数进行分层，比例为 1:1。
PACE Steps to Success Program 是一项将基本非专科姑息治疗整合到养老院中的多组分干预措施。采用培训师培训方法，外部培训师支持养老院的工作人员在为期 1 年的时间内按照 6 个步骤的方案引入姑息治疗方法。这 6 个步骤是：（1）与居民和家属进行预先护理计划；（2）评估、护理计划和需求及问题的审查；（3）通过每月的多学科审查会议进行护理协调；（4）提供以疼痛和抑郁为重点的高质量护理；（5）生命最后几天的护理；（6）死亡后的护理。
主要的居民结果是在死亡后由工作人员使用临终痴呆量表舒适度评估在死亡中（EOLD-CAD；范围，14-42）评估的生命最后一周的舒适度。主要的员工结果是工作人员使用姑息护理调查（PCS；范围，0-1）报告的姑息护理知识。
关于已故居民，我们从 37 个干预组和 36 个对照组的 37 家养老院中的 610 名工作人员中收集了 551 份基线和干预后 1178 份中的 984 份问卷。死亡时的平均（SD）年龄在 85.22（9.13）和 85.91（8.57）岁之间，在不同组中，分别有 60.6%（160/264）和 70.6%（190/269）的居民为女性。干预组和对照组居民的生命最后一周的舒适度没有差异（基线调整后的平均差异，-0.55；95%CI，-1.71 至 0.61；P = .35）。关于员工，我们从 37 个干预组和 38 个对照组的 3638 份问卷中收集了 2680 份，在干预后 3510 份中收集了 2437 份。工作人员的平均（SD）年龄在 42.3（12.1）和 44.1（11.7）岁之间，在不同组中，分别有 87.2%（1092/1253）和 89%（1224/1375）的工作人员为女性。与对照组相比，干预组的工作人员对姑息护理的知识有统计学上显著的改善，但临床差异很小（基线调整后的平均差异，0.04；95%CI，0.02-0.05；P < .001）。数据分析于 2018 年 4 月 20 日开始。
引入 PACE 成功计划后，居民生命最后一周的舒适度没有改善。员工对姑息护理知识的提高在临床上并不重要。
ISRCTN 标识符：ISRCTN85267463.
