How can advance care planning improve end of life care for nursing home residents?
How PEACE planning can guide nursing home staff and community nursing teams
For nursing home residents living with complex co-morbidities, including frailty, unplanned hospital admissions can be a common occurrence (McGlade et al 2017). Such admissions are associated with a decline in functional status, problems unrelated to the reason for admission, and increased mortality rates during admission and after discharge (Graverholt et al 2011).
Advance care planning (ACP) benefits nursing home residents, particularly those living with dementia. Benefits include: a reduction in subsequent hospital admissions; improved compliance with the person’s end of life care wishes, including those for preferred place of death; and a reduction in hospital death.
ACP is a process of engagement with the person, their family and a member of the nursing home team. This promotes inclusivity and personalisation, ensuring the wishes of the person are met (NHS England et al 2018). This is especially important if the person lacks mental capacity and best interest decisions must be made on their behalf.
One model of ACP is PErsonalised Advisory CarE (PEACE) planning (Benson and Mucci 2015), which is modified from the work of Hayes et al (2011). It determines what care should look like in the event of a predictable deterioration in the person’s life-limiting conditions, which can include advanced dementia or Parkinson’s disease (East Sussex Healthcare NHS Trust 2013).
The PEACE plan is an outcome of the comprehensive geriatric assessment, and records discussions between the person and/or their representative if they lack capacity and nursing home staff. These discussions can include topics such as management of infections and determining whether they may benefit from hospital admission.
The PEACE plan is an advisory document and serves to guide nursing home staff, GPs, paramedics, and palliative and community nursing teams. Therefore, information sharing and distribution of the plan to all relevant teams is an essential part of the PEACE planning process. Existing ACP information is incorporated into the plan, including do not attempt cardiopulmonary resuscitation decisions and advanced directives. If the person has a lasting power of attorney for health, they will also be consulted.
The plan improves the nursing home team’s confidence in clinical decision-making, leading to a higher threshold for hospital admission and ensuring the person’s end of life care wishes are respected. It is not a one-off process and should be iterative, or acknowledge that the person’s wishes and care preferences may change with their health status.
Ultimately, PEACE planning gives a voice to nursing home residents, allowing them and their families to have a say in their future care. Evidence from a recent survey suggests that this is highly valued by relatives, with 92% indicating satisfaction with their involvement in the PEACE planning process (Lyne and Mucci 2018). This is especially important for nursing home residents with dementia who do not always experience good quality end of life care (Care Quality Commission 2016).
- Benson D, Mucci M (2015) A future care planning initiative to improve the end of life care of patients on the complex care ward of a district general hospital. Future Hospital Journal. 2, 2, 87-89.
- Care Quality Commission (2016) A Different Ending: Addressing Inequalities in End of Life Care.
- East Sussex Healthcare NHS Trust (2013) The PEACE Plan – Information for Families and Carers.
- Graverholt B, Riise T, Jamtvedt G et al (2011) Acute hospital admissions among nursing home residents: a population-based observational study. BMC Health Services Research. doi: 10.1186/1472-6963-11-126
- Hayes N, Kalsi T, Steves C et al (2011) Advance care planning (PEACE) for care home residents in an acute hospital setting: impact on ongoing advance care planning and readmissions. BMJ Supportive & Palliative Care. 1:99.
- Lyne S, Mucci M (2018) Frailty Practitioner-Led PErsonalised Advisory CarE (PEACE) Planning for Care Home Residents in East Sussex: a Survey of Relatives' Satisfaction (poster). Unpublished. East Sussex Healthcare NHS Trust, St Leonards-on-Sea.
- McGlade C, Daly E, McCarthy J et al (2017) Challenges in implementing an advance care planning programme in long-term care. Nursing Ethics. doi: 10.1177/0969733016664969
- NHS England, Dementia Team and End of Life Care Team (2018) My Future Wishes: Advance Care Planning (ACP) for People with Dementia in All Care Settings. NHS England, Redditch.
About the authors
Sue Lyne, nurse consultant for frailty and older people, East Sussex Healthcare NHS Trust
Elena Mucci, consultant geriatrician, East Sussex Healthcare NHS Trust