背景:建议以舒适为重点的营养顺序来管理接近生命终点的长期护理(LTC)居民的饮食变化,尽管对它们目前的使用知之甚少。这项调查旨在描述当前的做法,并确定在这种情况下与以舒适为中心的营养顺序相关的居民水平和时间依赖性因素。
方法:回顾性地从死者(≥65岁的死亡,承认≥6个月)在安大略省南部的两个抽样帧中的18个LTC家庭中,加拿大。观察发生在6个月(基线),3个月,死亡前1个月和2周。提取的数据包括功能测量(例如认知表现,健康不稳定)在基线,在每个时间点进行正式的恢复性和以舒适为中心的营养护理干预措施,并在每个时间点之后的2周内在进度记录中报告饮食变化。逻辑回归和时变逻辑回归模型确定了与接受以舒适为中心的营养顺序相关的居民水平(例如功能特征)和时间依赖性因素(例如饮食变化)。
结果:164名参与者(61.0%为女性,平均年龄=88.3±7.5岁)中不到三分之一(30.5%;n=50)接受了以舒适为中心的营养订单,而大多数(99%)接受了至少一种恢复性营养干预以支持口服食物摄入。停止营养干预的情况很少见(8.5%)。舒适订单更可能与健康不稳定(OR[95%CI]=4.35[1.49,13.76]),死亡2周内(OR=5.50[1.70,17.11]),当生命结束对话自上一个时间点(OR=5.66[2.83,11.33])发生时,停止营养干预(OR=6.31[1.75,22.72]),同时发生其他护理计划修改(OR=1.48[1.10,1.98])和更多的饮食变化(OR=1.19[1.02,1.38]),尤其是吞咽困难(OR=2.59[1.09,6.17]),在前一个时间点。
结论:只有不到三分之一的死者开始了以舒适为重点的营养订单,而且通常是在生命的最后阶段,可能代表错失了支持这一弱势群体生活质量的机会。饮食变化的增加,包括新的吞咽困难,这可能表明需要进行涉及舒适营养护理选择的积极的临终对话。
结论:在LTC工作的老年护理团队中,应鼓励和计划与居民和家人就潜在的饮食变化和以舒适为中心的营养护理选择进行早期和公开的对话。这些对话可能是有益的,甚至早在居民进入家庭。
BACKGROUND: Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context.
METHODS: Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order.
RESULTS: Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint.
CONCLUSIONS: Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options.
CONCLUSIONS: Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.