title: Interventions for improving palliative care for older people living in nursing care homes.
abstract: BACKGROUND
  Residents of nursing care homes for older people are highly likely to die there, making these places where palliative care is needed.
  
  
  OBJECTIVE
  The primary objective was to determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people. The secondary objective was to describe the range and quality of outcome measures.
  
  
  METHODS
  The grey literature and the following electronic databases were searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (all issue 1, 2010); MEDLINE, EMBASE, CINAHL, British Nursing Index, (1806 to February 2010), Science Citation Index Expanded & AMED (all to February 2010). Key journals were hand searched and a PubMed related articles link search was conducted on the final list of articles.
  
  
  METHODS
  We planned to include Randomised Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), controlled before-and-after studies and interrupted time series studies of multi-component palliative care service delivery interventions for residents of care homes for older people. These usually include the assessment and management of physical, psychological and spiritual symptoms and advance care planning. We did not include individual components of palliative care, such as advance care planning.
  
  
  METHODS
  Two review authors independently assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Meta analysis was not conducted due to heterogeneity of studies. The analysis comprised a structured narrative synthesis. Outcomes for residents and process of care measures were reported separately.
  
  
  RESULTS
  Two RCTs and one controlled before-and-after study were included (735 participants). All were conducted in the USA and had several potential sources of bias. Few outcomes for residents were assessed. One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported group differences on some process measures. Both reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital in the intervention group, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions.
  
  
  CONCLUSIONS
  We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost-effectiveness, and reducing bias.
authors.affiliation: Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, Bessemer Road, Denmark Hill, London, UK, SE5 9PJ.
authors.forename: Sue
authors.initials: S
authors.lastname: Hall
authors.forename: Anna
authors.initials: A
authors.lastname: Kolliakou
authors.forename: Hristina
authors.initials: H
authors.lastname: Petkova
authors.forename: Katherine
authors.initials: K
authors.lastname: Froggatt
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
mesh_terms: D000368:Aged; D018849:Controlled Clinical Trials as Topic; D006707:Homes for the Aged; D017051:Hospice Care / Q000706:statistics & numerical data; D006801:Humans; D009735:Nursing Homes; D017063:Outcome Assessment, Health Care; D010166:Palliative Care / Q000458:organization & administration* / Q000592:standards; D017060:Patient Satisfaction