Length of stay and palliative care: understanding long-term care facility residents in Europe
By Danni Collingridge Moore
Background: A key consequence of population ageing will be an increase in the number of care-dependant older adults, unable to remain living in the community until death. The importance of developing long-term care systems to meet the care needs of this group has been recognised in international health policy on ageing; however, the role of long-term care facilities (LTCFs) has received less attention. An understanding of the variation in how long older adults reside in such facilities after admission, the implications of length of stay for palliative care provision, and how palliative care can be implemented successfully in these settings, is urgently needed.
Aim: The overarching research question of this thesis is ‘How are resident length of
stay and palliative care in long-term care facilities associated?’ Firstly, it aims to
systematically identify, synthesise and quality assess factors associated with resident length of stay in LTCFs. Secondly, to explore the association of resident, facility and country characteristics with length of stay in LTCFs. Thirdly, to explore the relationship between length of stay and care at end of life in LTCFs, and fourthly to
identify facilitators and barriers to implementing palliative care interventions in LTCFs.
Methods: A systematic review was conducted to identify factors associated with length of stay until death in LTCFs, and data assessed and synthesised using an existing tool adapted specifically for this review. Time to event analysis was
conducted on internationally comparable data collected in a mortality follow-back
study of 1,707 deceased LTCF residents in six European countries. Using the same
dataset, generalised linear mixed models were used to explore the relationship
between length of stay and five indicators of care at end of life. Finally, a scoping
review of implementation strategies used in organisational level interventions that
aimed to improve palliative care in LTCFs was conducted, using thematic synthesis to analyse the data.
Results: The thesis identified heterogeneity in the length of stay of LTCF residents,
explained by the “theoretical framework of deferred admission”. It found that longer
stay residents were more likely to experience better outcomes on indicators of palliative care, and produced a three-stage framework of implementation for
palliative care interventions in LTCFs.
Conclusion: In applying the theoretical framework of deferred admission, the thesis argues that length of stay is explained though the interplay of a resident’s intrinsic capacity and their environmental resources. These findings can guide the implementation of palliative care for all LTCF residents by identifying subgroups likely to experience poorer indicators of palliative care.