Effects of staff training on end-of-life care in long-term care facilities

Background: Older people residing in long-term care facilities (LTCFs) are known to have unmet needs in end-of-life (EOL) and palliative care. Their care can be improved through better advance care planning and by setting appropriate goals for care. In addition, providing facilities with adequate skills and resources helps in managing acute condition changes and meeting the palliative care needs of the residents without hospitalizations, which are known to be burdensome for this frail population.

Objectives: The purpose of this study was to examine the efficacy of staff training on LTCF residents’ EOL care outcomes. The study comprises four published sub-studies. In Study I, we systematically reviewed previous randomized trials examining the effectiveness of various interventions including staff education on residents’ EOL outcomes. Studies II–IV present a novel form of educational intervention to train staff members in key aspects of EOL care over four afternoons. This intervention was tested in a cluster-randomized controlled trial (RCT) in Helsinki in 2018 – 2020.

Participants: Study I was a systematic literature review. This review included database searches of MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, as well as study of references in key articles, previous reviews, and recent volumes of relevant journals. The review presents a narrative summary of 16 RCTs meeting the inclusion criteria. The studies involved between 72 and 23 478 resident participants per trial and overall they provided data on 40 712 LTCF residents. The RCT presented in Studies II–IV involved 324 residents and 132 staff members from municipally run LTCFs. The participating residents were randomized in facility-clusters to intervention and control groups.

Intervention: In the RCT, a training intervention was offered to all staff members of the facilities in the intervention group. The training intervention included four educational workshops (four hours each) on palliative care principles. Training contents included: advance care planning, adverse effects of hospitalization, symptom management, communication, supporting proxies, and challenging situations. Educational sessions were based on constructive adult learning methods and included a plentitude of resident cases, role-plays, and small-group discussions.

Measures: Resident-level outcomes were targeted in all sub-studies. Reported measures of quality of life (QoL), Quality of dying (QoD) or hospitalizations were required for all studies included in the systematic review. In the RCT, health-related QoL (using the 15D instrument) and hospital inpatient days during a two-year follow-up were taken as primary outcomes. Additionally, for a period of one year, residents’ symptoms, pain, psychological well-being, and proxies’ satisfaction with care were assessed. Intervention feedback results from trainees are reported in Study II.

Results: Study I revealed that previous randomized trials had mainly failed to produce benefits to residents. Low to moderate levels of evidence suggest that promoting advance care planning, increasing relatives’ involvement in decision-making and providing facilities with external palliative care expertise may improve QoD and reduce hospitalizations. In the RCT, QoL declined in both groups during follow-up, and no difference was observed in changes between the groups. Neither the number of hospital inpatient days (1.87 vs. 0.81 per person-year) nor the number of emergency department visits differed between the intervention and control groups. Total hospital expenditure was similar in the intervention and control groups. The change in ESAS symptom scores from baseline to six months favored the intervention group. However, the finding was not maintained later at 12 months. Pain, psychological well-being and proxies’ satisfaction with care were unaffected by the intervention. All follow-up analyses were adjusted for age, gender, do-not-resuscitate order, need for help, and clustering.
To conclude, the current evidence can only support rather specific interventions targeting resident-level EOL outcomes in LTCFs. Unsupported educational interventions might be insufficient in affecting meaningful resident outcomes.