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Timely personalized care for older people in the last phase of life

Projectomschrijving

POWER: Proactieve zorgplanning voor Ouderen in de Wijk

Veel ouderen spreken niet over voorkeuren rondom het levenseinde. Daarnaast beheersen wijkverpleegkundigen en verzorgenden nog niet altijd de kennis en vaardigheden om deze gesprekken te voeren (advance care planning (ACP)).

Rollen en verantwoordelijkheden

Dit komt mede door onduidelijkheid in rollen en verantwoordelijkheden rondom ACP. Dit leidt er mede toe dat ouderen niet overlijden op de plaats van voorkeur, een hoge symptoomlast ervaren en er vaak sprake is van ongewenste overgangen in de laatste maanden van het leven.

Doel: tijdige gepersonaliseerde zorg

Dit project heeft als doel om tijdige gepersonaliseerde zorg aan ouderen in de laatste levensfase te bieden die thuiszorg ontvangen.

Werkwijze

Als eerst wordt in kaart gebracht of en hoe voorkeuren veranderen over de tijd. Daarnaast wordt bepaald wat de succesfactoren zijn van ACP. Met deze kennis en al bestaande kennis over ACP wordt vervolgens een op maat interventie samengesteld. Deze interventie wordt vervolgens geïmplementeerd en geëvalueerd.

Verslagen


Samenvatting van de aanvraag

Advance care planning (ACP) conversations about the preferences, values, goals, wishes and needs of older people in the last phase of life are predominately initiated late, if at all. This is caused by the difficulty to predict the disease trajectory in the last phase of life, especially in frail older people, making it harder to find the right time to start ACP. Moreover, general health care professionals, such as district nurses often lack the knowledge and skills in ACP. Older people and their informal caregivers are unaware of their own role in ACP and are awaiting others to start the conversation. As a result older peoples’ preferences and wishes remain largely unheard, resulting in acute (and unwanted) transitions between care settings in the last months of life, a high symptom burden, reduced quality of life and not dying at the preferred place. Two-third of older persons receiving district nursing experience care transitions in the last year of life, although they are often seen on a daily basis. There might be a huge potential to optimize patient-relevant outcomes by better identification, starting regular ACP conversations and reducing symptoms. Therefore, the overall aim of this proposal is to provide timely personalized care to older people in the last phase of life receiving district nursing to prevent acute (and unwanted) transitions between care settings, facilitate dying at the preferred place, decrease symptom burden and improve quality of life. This proposal follows the Medical Research Council (MRC) framework for the development, implementation and evaluation of complex interventions. As such, this project consists of four phases: In phase 1, a cohort multiple randomized controlled trial design (cmRCT) will be set up in older people receiving district nursing care to 1) evaluate changes in older peoples’ preferences and goals regarding personalized care in last phase of life and 2) evaluate what (i.e. timing, content, setting, health care professional) determines the benefits of ACP in the last phase of life of older people in terms of acute care transitions, symptom management, quality of life and dying at the preferred place. In phase 2, intervention mapping will be conducted to explore the role of health care assistants, district nurses and nurse practitioners in ACP conversations with older people with district nursing. In this phase the knowledge of phase 1 will be used and all relevant evidence on ACP methods suitable for district nursing will be summarized. In co-creation with health care professionals, nursing students, educators and older people, an intervention to apply and integrate ACP in district nursing will be formulated and tested for feasibility. In phase 3, the ACP intervention from phase 2 will be evaluated using the cmRCT from phase 1. A selection of older people will be randomized to an intervention group in which potentially multiple ACP methods from phase 2 will be separately tested. Alongside the effectiveness study a process evaluation and a cost-effectiveness analysis will be conducted. In phase 4, the results of this project will be disseminated and implemented. The collaboration between a health care organization that provides district nursing, an university of applied sciences, school of nursing and an university network in care for older persons will facilitate dissemination to daily practice and nursing curricula.

Kenmerken

Projectnummer:
10040022110006
Looptijd: 57%
Looptijd: 57 %
2021
2026
Onderdeel van programma:
Gerelateerde subsidieronde:
Projectleider en penvoerder:
M. van Rijn PhD
Verantwoordelijke organisatie:
Amsterdam UMC Locatie VUmc
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Marjon van Rijn

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Talentontwikkeling

Met leertrajecten en persoonsgebonden subsidies ondersteunen we talentvolle verpleegkundigen, verpleegkundig specialisten en verzorgenden in de ontwikkeling van hun persoonlijke leiderschapskwaliteiten. Zodat zij hun zeggenschap kunnen vergroten en zelf invloed kunnen uitoefenen op het beleid en de financiering in de zorg. Lees wat we nog meer doen.