When I was an ED nurse in a city hospital years ago, we often received patient transfers from area nursing homes. Usually these patients were very elderly, appeared cachectic, and were largely unresponsive (as I recall, many were post-stroke or had dementia). Diagnoses were usually very similar: dehydration, hypotension, UTI, pneumonia; many had contractures. The usual care was rehydration with IV fluids, an NG tube, antibiotics, and often a Foley catheter. Sometimes they were septic and then they were intubated, placed on ventilators, and sent to the ICU, where just about everyone died after a short stay.

What’s the point of this care?

I often wondered, as did many of my colleagues, what was the point of this. It seemed futile, and injurious to the patient. Sometimes, if we could reach family members before nasogastric or endotracheal tubes were placed, we were able to secure an order to dispense with all but comfort measures. Otherwise, all measures were initiated and then things became complicated—legal issues arose about discontinuing futile care and families often couldn’t bring themselves to discontinue life support measures.

Today, a greater focus on advance care planning.

Advance care planning (ACP) was hit or miss in those days—mostly miss—and our patients suffered because of this. It’s only recently that emphasis has been placed on making decisions about end of life care early, when one can still make choices about how much care they wish to receive. But surprisingly little research has been done to explore how ACP is done in one of the populations who may need to focus on this more than most—those in skilled nursing facilities and nursing homes. Given that the proportion of the population that is elderly is rising, this is an area that needs attention.

Who does it, when, and do they feel prepared?

In the December issue of AJN, we’re pleased to present an original research article, “Advance Care Planning: An Exploration of the Beliefs, Self-Efficacy, Education, and Practices of RNs and LPNs,” which explores advance care planning in skilled nursing facilities by RNs and LPNs—who does it, when, and do they feel prepared and able to do it.

This is important research because, as the authors note,

“Nurses are often the first to recognize a resident’s deteriorating health and to interact with family members during such times; they are also often looked to for answers to questions about documents such as advance directives and do-not-resuscitate (DNR) orders.”

And while LPNs spend more time with patients than RNs, who tend to manage more administrative tasks, LPNs were more likely to feel that ACP discussions were not part of their role.

The study by authors from Kent State University and Northeast Ohio Medical University was supported through a grant from the Agency for Healthcare Research and Quality (AHRQ). You can read the study for free, earn CE credit, and listen to a podcast with two of the authors (click on the podcast icon on the article page).