Table 3.

Top clinical practice interventions, communication factors, and policy/regulatory considerations required to improve end of life care in long term care facilities

Clinical Practice Knowledge and Skills

1. Develop, provide, and monitor compliance with an imminently dying pathway for use specifically at end of life 2. Create a communication checklist that physicians can adapt and use in conversations with LTC residents and their family for consistent messaging 3. Provide dementia education to staff that shows how dementia compromises health and limits life 4. Provide physicians/LTC staff with peer mentoring and access to the coaching and support of palliative care consultants 5. Provide palliative skills assessment and training specific to each health discipline 6. Provide palliative care knowledge, skills, and care standards though flexible pathways adaptable to diverse computer systems 7. Institute using the CHESS (Changes in Health, End-Stage Disease, Signs and Symptoms) quarterly rather than yearly to increase familiarity and better anticipate end of life 8. Include pain as a vital sign in routine assessments 9. Involve families in symptom management decisions

Communication Factors

Conversation 1. Use de-prescribing as a conversation opener to build relationships with families and enable future conversations about taking a palliative approach to end-of-life care 2. Perceive conversation with family as continuous and utilize current resources, such as the Serious Illness Conversation Guide [23] to unpack expectations 3. Have timely and open conversations between family and care providers Language/Word Use 4. Develop and use consistent end of life language in documents and face to face conversations when discussing care from admission to end of life 5. Clarify the meaning of “family” for each resident and the degree of family engagement desired 6. Remove unhelpful wording such as “authority” and the valuing of professional over lay expertise Care Behaviours/Practices 7. Use end of life order sets with caution as they can limit critical thinking and prevent validation of resident and family ideas about death and dying 8. Physicians to start palliative care approaches on admission and to routinely inform staff and family about changes in health status 9. Physicians regularly engage with families by writing a letter of expectations of families, attending family meetings, and dedicating time to meet with families throughout admission to end of life Attitudes 10. Incorporate team-building exercises into physician/LTC staff skills development training 11. Encourage sharing of thoughts, feelings, and ideas about life and death 12. Regard families as partners in care with experts 13. Create a social environment that makes it possible for healthcare aides to speak openly without fear 14. Perceive spiritual care as possibly, but not necessarily, connected to a system of beliefs or religion

Policy/Regulatory Considerations

Physical Design Factors 1. Legislate a government policy to mandate and regulate having access to private spaces within a LTC facility when death is imminent 2. Provide more recreational space and opportunities for socialization 3. Establish a separate space for spiritual contemplation 4. Provide a private space that families can use for talking and reflecting when approaching end of life Social Design Factors 5. Regulate increases in number of available staff at end of life, and assure continuity of staff for resident and family 6. Provide families with access to multi-disciplinary support 7. Create policies at the management, system, and government levels in order to mandate resident and family centered principles and processes 8. Enable, fund and enact resident and family centered care throughout the care trajectory within LTC