Me & My Wishes: an Examination of Resident Preferences in Nursing Home Care Conferences

With an increasingly older population in the United States, many older adults are expected to dwell in nursing homes (NHs)-a place where they may also experience the end of their life (EOL). Despite the growing number of older adults in NHs, meaningful discussions about preferences for end-of-life (EOL) care seldom occur between residents, NH staff, and / or residents' family members. The lack of communication results in missed opportunities to know, understand or implement residents' preferences. Missed conversations about EOL preferences have the potential to result in poor patient outcomes such as stress, fear and unnecessary pain during EOL. Me & My Wishes is a person-centered care approach where long-term care residents create videos. In their videos, residents tell us about themselves and the type of care they prefer. The videos are then shared with NH staff and family in the scheduled care conference meeting. For this qualitative content analysis, I analyzed 11 transcripts of 11 care conferences. Five transcripts were from care conferences prior to viewing the resident's Me & My Wishes video, and six were from care conferences when the video was shown. I identified codes a priori based on published literature and during an initial read-through of the transcripts, and then proceeded to code each transcript based on the identified codes with highlighting tools. During this process, more codes were identified and refined. Codes were next separated into corresponding categories, which were then defined, summarized and analyzed. Three objective questions relating to discussions surrounding resident preferences and person-centered care came from transcripts of care conferences before sharing the Me & My Wishes video as well as conferences that iii included the video and were used as a guide to analysis of the categories. Topics that were discussed during the care conferences included but were not limited to: resident history (i.e. medical and social history), preferences for current care (i.e. dietary, activity, medication and daily living), and preferences for EOL care (i.e. Physician Orders for Life-Sustaining Treatment forms). Based on excerpts from the care conferences and supporting literature, I developed recommendations for future care conferences relating to the integration of person-centered care.

ME & MY WISHES: AN EXAMINATION OF RESIDENT PREFERENCES IN NURSING HOME CARE CONFERENCES by Abigail Busath A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirements for the Honors Degree in Bachelor of Science In Nursing Approved: ______________________________ Gail Towsley, PhD, NHA Thesis Faculty Supervisor _____________________________ Connie Madden, PhD, RN Chair, College of Nursing _______________________________ Sara Simonsen, PhD, CNM, MSPH, BSN Honors Faculty Advisor _____________________________ Sylvia D. Torti, PhD Dean, Honors College May 2019 Copyright © 2019 All Rights Reserved ii ABSTRACT With an increasingly older population in the United States, many older adults are expected to dwell in nursing homes (NHs)—a place where they may also experience the end of their life (EOL). Despite the growing number of older adults in NHs, meaningful discussions about preferences for end-of-life (EOL) care seldom occur between residents, NH staff, and / or residents’ family members. The lack of communication results in missed opportunities to know, understand or implement residents’ preferences. Missed conversations about EOL preferences have the potential to result in poor patient outcomes such as stress, fear and unnecessary pain during EOL. Me & My Wishes is a person-centered care approach where long-term care residents create videos. In their videos, residents tell us about themselves and the type of care they prefer. The videos are then shared with NH staff and family in the scheduled care conference meeting. For this qualitative content analysis, I analyzed 11 transcripts of 11 care conferences. Five transcripts were from care conferences prior to viewing the resident’s Me & My Wishes video, and six were from care conferences when the video was shown. I identified codes a priori based on published literature and during an initial read-through of the transcripts, and then proceeded to code each transcript based on the identified codes with highlighting tools. During this process, more codes were identified and refined. Codes were next separated into corresponding categories, which were then defined, summarized and analyzed. Three objective questions relating to discussions surrounding resident preferences and person-centered care came from transcripts of care conferences before sharing the Me & My Wishes video as well as conferences that iii included the video and were used as a guide to analysis of the categories. Topics that were discussed during the care conferences included but were not limited to: resident history (i.e. medical and social history), preferences for current care (i.e. dietary, activity, medication and daily living), and preferences for EOL care (i.e. Physician Orders for Life-Sustaining Treatment forms). Based on excerpts from the care conferences and supporting literature, I developed recommendations for future care conferences relating to the integration of person-centered care. iv TABLE OF CONTENTS ABSTRACT ii INTRODUCTION 1 METHODS 6 RESULTS 9 DISCUSSION 18 RECOMMENDATIONS 20 CONCLUSION 23 REFERENCES 25 TABLE 26 1 INTRODUCTION The United States Census Bureau calculates that by the year 2030, the number of adults aged 65 or older will outnumber children for the first time in the country’s history (2017 National Population Projections). For the first time, the United States will have an exponentially larger number of older adults that will comprise a daunting patient demographic the U.S. healthcare systems haven’t seen before. Currently, about 1.4 million older adults reside in nursing homes (NHs) (CDC, 2015) – places that provide residence, medical care, and assistance in activities of daily living (ADLs), such as bathing, dressing, eating, toileting and ambulation. Residents require such services due to complex and/or chronic medical conditions that make it difficult or impossible for them to continue living independently. Skilled nursing facilities, also known as nursing homes, provide rehabilitation and therapies such as physical and occupational therapy in addition to services such as 24-hour nursing care and ADL assistance. One in four residents are expected to experience end of life (EOL) in NHs (Brock & Foley, 1998). Despite the many individuals expected to experience the end of their life in NHs, a lack of communication about EOL preferences occurs among nursing home staff, residents, and family members. Topics about EOL preferences may include what kind of care, pain management, and experience patients can expect at the EOL, in addition to religious, dietary, and preferred treatments during their everyday life. Missed opportunities to know, understand or implement residents’ preferences (Towsley & Hirschman, 2017) can result in poor patient outcomes such as undue stress, frustration, fear, loss of dignity, and unnecessary pain during the EOL process (Cagle, 2 Unroe, Bunting, Bernard & Miller 2017). Conversations regarding resident preferences need to be held before the end of life, documented, revisited routinely, approved by the resident, amended as needed, and shared between all members of staff and family associated with each resident (at the resident’s discretion). In 1987, the Nursing Home Reform Act (NHRA) was passed. The purpose of the NHRA was to “attain or maintain [residents’] highest practicable physical, mental, and psychosocial well-being” (NHRA, 1987). A Resident’s Bill of Rights was established, seeking to give residents freedom and facilitate the right to be involved in the planning and review of their care plan, and to keep them informed of any changes made to that plan (NHRA, 1987). Despite improvements from the enactment of the NHRA, delivering person-centered care remains challenging. The term “culture change” refers to a movement that aims to change the way NHs provide care – as personalized homes that also happen to include long-term care services, rather than medical institutions (Koren, 2010). This movement encompasses the notion of “person-centered care” - an important aspect of NH care that focuses on the individuality of each person. For example, person-centered care consists of involving residents in making decisions or providing input regarding their medical and/or psychosocial care (e.g. medication changes, personal interactions, and participation in activities). Personcentered care additionally supports residents in achieving the highest degree of wellbeing by keeping them central in the care-planning process, and also understands the importance of fostering satisfying relationships between patients and caregivers in healthcare (Håkansson Eklund, et. al, 2019). Culture change also specifically focuses on staff empowerment by emphasizing the teamwork, practices, and policies necessary for 3 staff to provide resident-centered care (Koren, 2010). Providing NH staff the resources to deliver person-centered care helps to improve the environment for both residents and staff (Koren, 2010). Research has examined whether the “culture change” shift has been implemented in NHs. While the findings of this research are conflicting due to small sample size and inconsistent implementation standards, there was one study that identified positive results from the implementation of culture change practices (Miller, Leopore, Lima, Shield & Tyler, 2014). In this study, Miller et. al (2014) described that the introduction of “culture change” practices was associated with a significant decrease in the prevalence of unpleasant resident treatments such as restraints, tube feedings and bladder training programs, along with a decrease in adverse patient outcomes such as pressure ulcers and resident hospitalizations per year. Palliative care is a person-centered model that aligns with culture change practices. Palliative care focuses on a person’s physical, intellectual, emotional, social, and spiritual needs while “facilitating patient autonomy, access to information and choice” (National Consensus Project for Quality Palliative Care, 2018). The World Health Organization ventures that palliative care will increase patients’ quality of life through “early identification, correct assessment and treatment” of symptoms such as pain or psychosocial needs (WHO, 2019). Palliative care can be incorporated into the care regimen long before a patient is in the process of dying. Palliative care is particularly appropriate for the NH setting at all stages of care because of the emphasis on communication, goal setting, autonomy, access to information and choice. Palliative care has shown that it not only can provide relief to many different patient symptoms such as 4 pain, nausea, and anxiety, but it can also decrease the burden on caregivers and, like the World Health Organization asserts, improve quality of life (Arora, et al, 2017). Despite positive results associated with palliative care in terms of facilitating person-centered care and patient health, there are still barriers to resident preferences being incorporated by NH caregivers. These barriers include a lack of discussion about EOL care between the resident and the care team (Parry, Lund, & Seymour, 2014), and even discomfort about bringing up the subject of EOL (Brighton & Bristow, 2016). In order to create a culture in which preferences are incorporated into resident-centered care plans, conversations about preferences and the EOL are essential. In nursing homes, care conferences are meetings that bring together “health care providers, the resident, and the resident’s family” to discuss patient goals, expectations, and preferences (Puurveen, Cooke, Gill & Baumbusch, 2018). Key members of the care conference comprise the interdisciplinary team – a group of staff members from various backgrounds in healthcare such as nursing, social services, and dietary (Halcomb, Shepherd & Griffiths, 2009) who “work together to share expertise, knowledge, and skills” to positively impact patient care (Nancarrow, et al, 2013). The care conference is a meeting where the various care team members can work together with the resident and their family (if the resident chooses) to create a cohesive, safe, and person-centered plan of care, though this may not always be the case due to a lack of uniform understanding and appreciation about care conferences and their role in patient care (Halcomb, et. al, 2009). In updated regulations set forth by the Center for Medicare and Medicaid Services (CMS) in 2016, it was specified that residents had the right to “participate in the planning process, identify individuals or roles to be included, request meetings and 5 revisions to the person-centered plan of care, and receive services and items included in the plan of care” (Medicare and Medicaid Programs; Reform of Requirements for LongTerm Care Facilities, 81 § Final Rule (2016)). The objective of care conferences is to provide an environment for open collaboration and to improve systematic communication around goals for every-day living and eventually the EOL (Durepos, et al, 2017). By adhering to the goals and objectives of the “culture change” movement and person-centered care, NHs have the opportunity – indeed the obligation – to ensure that residents can participate in their plan of care encompassing their own preferences and wishes. Me & My Wishes is a person-centered care approach where long-term care residents create videos. In their videos, residents talk about what matters to them and the type of care they prefer (Towsley, Beck, Ellington & Wong 2016). Videos are then shared with NH staff and family in the care conference meeting. In Me & My Wishes, residents respond to questions in four categories: 1. About Me (biography), 2. Preferences for Today (types of day to day care they prefer while living in the NH), 3. Preferences for Medical Interventions (types of care they prefer when they become more sick or dying), and 4. Afterthoughts (after they pass away, what do they want to happen?). Videos are a way for residents to relay their preferences using both audio and visual and offering an opening to a conversation between the care team, family and the resident. This intervention may facilitate the integration of culture change by helping providers to address resident wishes as described by Towsley, Beck, Ellington and Wong in 2016. Personalized videos are approved by the resident before being shared with 6 members of the care team (staff and family) during a scheduled care conference (Towsley et al., 2016). The purpose of my project was to qualitatively examine the content of the care conferences before sharing the Me & My Wishes video and at the time of viewing the Me & My Wishes videos. More specifically, I examined how the care team talks about and incorporates resident preferences during care conferences. The objectives of this project were to: 1. Describe topics covered during the care conference that pertain to resident preferences and person-centered care. 2. Ascertain how the care team integrates resident preferences in the care conference before watching the Me & My Wishes video, 3. Ascertain how the care team integrates resident preferences in the care conference at the time of viewing the video. 4. Make recommendations to the interdisciplinary team to incorporate resident preferences into care planning and the care conference meeting. METHODS The content of 11 care conferences taken from three nursing homes were examined. Care conferences were audio recorded and lasted between 12 and 38 minutes. Five transcripts were recorded during care conferences prior to sharing the residents’ Me & My Wishes video. Six transcripts were recorded during care conferences that shared the residents’ Me & My Wishes video. Audio recordings were transcribed verbatim and all identifiers (names of residents, staff, family and the NH) were removed. The 7 following steps were used to analyze the transcripts and are informed by qualitative content analysis by Hsieh and Shannon (2005): 1. Transcripts were read through in their entirety. A few codes were identified a priori based on published literature. For example, codes such as introduction of team members to the resident, respectful language, resident biography, current care preferences, and family involvement in the care conference were identified a priori. Other codes such as resident concern / questions were identified during the initial reading of transcripts. Codes were chosen based on project objectives, the topics identified during initial read through of the transcripts, and topics based on the literature related to person-centered care. Information about each resident such as personal history, dietary preferences, activity level, medical care, and EOL preferences were examined from the care conferences during the coding process because they are unique to each individual, which not only helps acquaint team members with residents, but also in this way allows for a more person-centered care approach. Codes utilized in this project were words or phrases such as “resident preference,” “attitude” and “resident history” that were used to reference a section of the transcript and provided a brief description of the section. 2. Transcripts were then “coded” by highlighting text in colors that corresponded to the specific codes. 3. Coded sections of each transcript were copied and pasted into word documents that grouped together codes that appeared similar in nature. Each coded section of a transcript was labeled with the transcript identification number. Each of these documents was referred to as a category document. 8 4. Categories were further developed by identifying similar codes and grouping them together. Initially, ten unique categories were identified. Overlapping codes or codes not clearly defined were then reviewed and revised or eliminated, resulting in six final categories. Categories were defined, summarized, and separated into two time domains: Before Time of Sharing the Me & My Wishes videos, and At the Time of Sharing the Me & My Wishes videos were shared. 5. For two categories (Resident / Family engagement during the care conference and the Me & My Wishes video incorporation during the care conference), additional labelling was included. In the Resident/Family engagement during the care conference category, care conferences were labelled as 1), “active engagement--,” meaning the resident and/or family member attended the care conferences, was actively engaged and made contributions without waiting for invitation from the care team each time they wanted to talk; 2) “passive engagement--,” meaning that the resident and/or family member attended the care conference and did not share thoughts, or only made contributions when invited by the care team; and 3) “no engagement” – meaning that neither the resident or family member attended the care conference. For the Me & My Wishes video category, each care conference was labelled as 1) “positive reception”, for care conferences where the video received positive feedback and had follow up discussions, 2) “neutral reception” for care conferences where the video did not result in post-viewing discussion, or 3) “negative reception” if the care conferences responded negative feedback. 9 6. Finally, based on the identified categories, excerpts from the care conferences, and published literature, six recommendations for future practice in nursing home care conferences were developed. RESULTS In preparing the initial coding scheme, some ideas were identified a priori. There were two groups of codes (Positive group and negative group) that were developed in reference to current literature recommendations. There were 26 codes in total between the two groups. The initial codes included examples such as team introductions, respectful interactions between the care team and resident, choice discussion and implementation, and resident / family involvement during the care conference. As I began reading the transcripts, some of the chosen codes were not as applicable, and were developed further. Finally, six categories were identified, revealing aspects of person-centered care during care conferences. Some of the categories fit in both time domains of Before and At the time of sharing the Me & My Wishes videos; their definitions and exemplars are presented in Table 1. The categories were: 1. 2. 3. 4. 5. 6. Respectful interactions. About the resident. Discussed resident preference for current care. Discussed resident preference for end-of-life care. Resident/Family engagement during the care conference. Me & My Wishes Video Incorporation during the care conference. Two of the categories (Respectful interactions and Resident/Family engagement during the care conference) describe relational interactions between caregivers (e.g. care conference team members) and residents rather than integration of resident preferences, 10 as the objectives of this project intended. However, person-centered care aspects such as respect, resident inclusion, and resident attendance were observed in the care conference transcripts and therefore, these categories were included in the results. Again, for the Resident / Family engagement category, each care conference was labelled either 1) “active engagement”, 2) “passive engagement”, or 30) “no engagement”. Six out of 11 care conferences were labelled as “active engagement,” three out of 11 care conferences were labelled as “passive engagement,” and two out of 11 care conferences were labelled as “no engagement.” The results regarding the three analytical objectives focused on resident preferences are presented below by each objective. Each objective includes a summary of the results from the relevant categories. Topics Covered During Care Conference Related to Preferences and PersonCentered Care Three categories addressed the objective about topics related to person-centered care. The categories include “About the resident”, “Discussed resident preferences for current care”, “Discussed resident preferences for end-of-life care” About the resident. The topics discussed in the category, “About the resident” included resident medical history (such as past/diagnoses, medical procedures, and medication) and social history (such as, financial situation, family dynamics, and home life). Discussed resident preferences for current care. The topics discussed in this category relate to preferences and person-centered care included dietary preferences (e.g., 11 less fruit for dessert, cutting pieces smaller before eating), activity preferences (e.g., crosswords puzzles in room, social event participation) and medical care preferences (e.g., medication changes). Discussed resident preferences for end-of-life care. The topics discussed in this category related to preferences and person-centered care involving resident preferences and options on the Physician Orders for Life-sustaining Treatment (POLST) form, such as Cardiopulmonary Resuscitation (CPR), artificial nutrition (feeding tubes), and intubation. How preferences were integrated before sharing the Me & My Wishes videos. Three main categories addressed integration of resident preference in conferences that occurred before the videos were shared. The categories are “About the resident”, “Discussed resident preferences for current care”, and “Discussed resident preferences for end-of-life care”. About the resident. Resident history was discussed during five out of five “before sharing the video” care conferences. All five of these transcripts included brief discussions about previous medical history. For example, one care conference staff member said: “[resident name] is very stable in mood and memory… Um, he takes, I believe, an antidepressant… Let’s double check… Yeah, he takes Zoloft... Ok…And that was, um I think last time we reviewed was in December.” 12 One resident shared, “I was in the hospital for pulmonary emboli, and when I was back here in January one of the therapists did a number on my shoulder”, and another resident said, “I have a social anxiety disorder.” Social histories were briefly discussed during two of these care conferences in addition to the medical histories. One instance focused on significant others and children. An example from a care conference team member included, Let’s see, his wife is in the hospital or at [facility name] transitional…his son told me …she sometimes comes and visits him here…we kinda had some issues scheduling the last care meeting because of some issues that she had going on. Discussed resident preferences for current care. Each of the five “before sharing the video” care conferences had discussions regarding resident preferences for day-to-day care. Food preferences were discussed during three out of the five care conferences. During one conversation between a resident and staff member, the resident said, “Food portions are a little large at times… Okay, is the food tasting okay?... Yeah… Mhm, anytime someone provides me with food I’m a happy cat… Same here.”, and another example of a conversation between staff and the resident included, You said that ‘the food is good most of the time’ but sometimes you wish you could have more desserts, right?... Yes, all those pretty desserts – it’s just fruit, plain old glob of fruit cocktail... Yeah, that’s because of the diet you are on…your doctor doesn’t want you eating concentrated sweets like cakes and cookies all the time. Activities of daily living concerns were discussed during four out of five care conferences. Discussions involved activities such as showering, spouse visitation, new wheelchairs, pet preferences, room and facility changes, and activity preferences like painting. Two examples of these conversations were; 13 I’m still detached from [Charlie the bird] …. I know you are struggling with that. One of the things we are working on is relocation for you to be closer to Charlie… Then I can have her with me again… Yeah if it is not a facility where we can have Charlie, perhaps it’s a facility where you’re at least closer to Charlie… No, it has to be with Charlie., and, I would like some Icy Hot packets put on my lower back because it really hurts and stops me [from getting up] ... Okay, you have hot pack and some muscle rub orders…. I want something that I can feel… Okay. Discussed resident preferences for end-of-life care. Only two out of five “before time of sharing” care conferences discussed EOL preferences. These discussions centered around POLST (Physician Order for Life-Sustaining Treatment) forms, resuscitation status, and nutrition therapy. One staff member said, “So I think we’re ready to move on to your code status. You’re full code – do you know what that means?...Oh, yes, heroic measures please…Okay so you want everything to happen…Yes…”, Another staff member said, “Do you have a POLST? Physicians order for life-sustaining treatment, you filled out when you got here – yep when you got here. Tell us, in the event of something happening, what would you like us to do?”, How preferences were integrated at the time of sharing the Me & My Wishes videos. Four main categories addressed resident preference integration at the time of sharing the videos. The categories were “About the resident”, “Discussed resident preferences for current care”, “Discussed resident preferences for end-of-life care”, and “Me & My Wishes video incorporation during the care conference”. 14 About the resident. Brief discussions about past resident history were held during six out of the six “time of sharing” care conferences. Medical history was discussed during five out of six care conferences. One staff member said, “Your BPH that you’ve had with urinary retention…you’ve been taking [medication name]. Does that sound right?”, Another staff member asked, “What does he have?... Um, he has had a stroke... Oh, okay… When did he have the stroke?” Social history was discussed during three out of the six care conferences including children, home life, and pets. One of these care conferences only discussed social history. One staff member said, “So, you know he has a daughter, and I think another one. I wonder if they don’t live here.”, and another one said, “[resident] is here just waiting for the ramp to be put in place so she can return home.” Discussed preferences for current care. Day-to-day preferences were discussed during all six of the “time of sharing” care conferences. Again, these preferences ranged from food, to care, and activities. Food preferences were discussed during four out of six care conferences. One staff member explained, “I know you like your raw carrots, so you need to keep wearing your teeth so you can eat raw vegetables…I know, it’s just been awhile, so I have to get used to wearing them again.”, and another conversation between staff and the resident said, [Staff]: She gets a lot of fruit for dessert because of her diabetes- I know you’re frustrated with that…[Resident]: I hate to get fruit…[Staff]:We could try sugar free options?...[Staff]: We don’t really do sugar free because studies say it’s not actually better for you…[Resident]:But that’s discrimination. 15 Activity preferences were discussed during four out of six care conferences, including conversations about things such as the activities the residents seemed to enjoy participating in, why they don’t want to participate, which activities they wanted to have in their room, and what activities they would like to learn more about. One resident explained, “I don’t participate in activities, because I have enough other things going on…Fair enough…although I do like the smoothies or ice cream socials once in a while…Oh, yeah…They’re really good”. A staff member asked one resident, “Is there anything particular you’d like to have in your room? Like word search, word cross, books-?...I had a crossword puzzle in there…Any magazines or books?...No, I can’t because my eyesight in this eye is going out…” ADL care was discussed during two out of six care conferences, including medications and equipment. One resident discussed their daily medication and one requested an electric wheelchair because her arms were too short to wheel herself. Examples of these conversations: Okay, would you like to see if we can try something different then?...Well anything I think would be an improvement. It’s just, well, it’s awful. I’m afraid to get away from the room almost…Yeah, okay. Well, Dr. F will be here tomorrow, and we can talk about it with her…Okay”, and, I’d like to have an electric chair – is there any chance of getting one of those?...So…I’ve seen them in the hall…So Medicaid does not pay for electric chairs…Who does?...Well people who have them pay for them privately…Well I had one when I got here and I was told they weren’t allowed, so I got rid of mine…In order to get a new wheelchair you have to show that you are making progress and you have to have the upper body strength to actually wheel yourself. 16 Discussed preferences for end-of-life care. EOL preferences were discussed during three out of six “at time of sharing” care conferences. Similar to the conferences that occurred prior to sharing the video, these discussions centered around POLST (Physician Orders for Life-Sustaining Treatment) forms, resuscitation status, nutrition interventions. One resident started as full code status, but then changed to DNR when it was explained what a “full code” status entailed. One conversation between a staff member and the resident was, Your POLST, tells us your wishes if you ever have any issues…Right…Do you want any changes on that…Probably would have to see it again to know for sure…You can come by my office any time and review it and we can make changes if needed…Okay….’Reviewed POLST’ ”, And another staff member offered to amend the POLST form after viewing the resident’s video by confirming with the resident that she did not want tube feeding. “…No feeding tube…I’m capitalizing the NO [resident laughs].” Me & My Wishes video incorporation during the care conference. Out of six care conferences that included viewing of the Me & My Wishes videos, four were labelled as “positive reception” because of the way the care team responded to the resident after viewing the video. These responses were mostly “Thank you”, “That was wonderful”, and “I’m glad I got to watch this.” The remaining two care conferences were labelled as “neutral reception,” because the care conference team members did not verbally respond after watching the video. None of the care conferences were labelled as “negative reception.” Out of the six care conferences, two included a viewing of the Me & My Wishes videos at the beginning of the conference. The other four were viewed during the middle 17 of the care conference. None of the care conferences included a viewing of the video at the end of the conference. Out of the six care conferences, two meetings involved viewing the video, but the meetings did not receive the video with any positive feedback, specifically, they did not thank the resident or mention that they enjoyed watching the video. One of these care conferences did not include the resident. The other, while being labelled as “neutral reception” did include a comment about video content later in the care conference. The other four care conferences also included conversations about content from the video, whether regarding EOL preferences or to day-to-day care preferences. One staff member immediately said of the video after viewing it, “We like to hear those because you know we don’t always get to spend that much one-one time with you and it’s nice to see the video and because we know… we have the pink POLSTS but we don’t actually get to know what you want we see it but we don’t get to hear what you want to do so I liked that.” Another staff member asked the resident questions about the video, and their conversation was, “And then [RES name], in the video you said, you like to, you used to do crafts… Yes, art crafts… So [name] is trying to get more crafts. Would you like to, would you be interested in maybe trying to do some crafts?... I could try but my hands don’t work that well.” Finally, one staff member noted that preferences on the POLST form differed from preferences shared in the video. She followed up with the resident by saying, “Okay? So [RES name] your POLST says that you want full treatment. But what you said in the video is different. So I’m gonna let [name] or [name] explain. Because they are nursing.” After this follow-up, the resident was able to explain that she did want her POLST form 18 changed, and watching the video reminded her of her preference, and the team was able to accommodate this request. DISCUSSION My examination of care conference transcripts addressed the three analytical objectives, “Describe topics covered during the care conference that pertain to resident preferences and person-centered care”, “Ascertain how the care team integrates resident preferences in the care conference before watching the Me & My Wishes video”, and “Ascertain how the care team integrates resident preferences in the care conference at the time of viewing the video”. The purpose in analyzing person-centered care aspects of NH care conferences was to identify what topics were being discussed and to determine what steps (if any) future NH care conferences could take to ensure residents were being given true person-centered care. In the 11 care conferences I analyzed, discussions surrounding day-to-day preferences made up the bulk of discussion, followed by EOL preferences, and resident history. This finding is clinically important because if the goal of care conferences is to establish resident preferences and to create a cohesive and personcentered plan of care, then the care conferences analyzed appeared to address topics that were indeed person-centered. However, in reference to my project objectives on identifying how the care team integrates preferences before and during viewing the Me & My Wishes videos, I noted that the EOL discussions were very limited in comparison to the day-to-day preferences (e.g., were only centered around POLST forms), and should have a greater emphasis within the care planning process. In addition to POLST form 19 options, other EOL preferences such as religious practices or family presence should be discussed. Two of the six categories describe relational interactions that were not key to my study objectives. However, these interactions involved important aspects of personcentered care. The two categories included information about how the resident was referred to (whether by name or a pronoun), and if the resident was included in the care conference by being introduced to team members. These categories were chosen in relation to another study conducted that examined resident and family involvement during care conferences (Puurveen et. al, 2018). Analysis of data from the current study revealed that most care conferences included “active engagement” of the resident, due to their involvement and the contributions they made to the discussion and plan of care. In addition to the three analytic study objectives, study data informed potential solutions to address the barriers that sometimes prevent the implementation of certain resident preferences. The results of this study indicated that the use of the Me & My Wishes videos can be used to facilitate difficult discussions and is useful in helping residents be engaged in their care planning. During the six care conferences that included viewing of the videos, four were labelled as “positive reception” because of the discourse that followed directly after the video was viewed. This finding is important because Towsley and Hirschman (2017) described many barriers to EOL conversations, such as the uncomfortable atmosphere and fear of distressing residents and introduced the Me & My Wishes tool as a facilitator for these conversations. Discussion opportunities about EOL are often missed (Towsley, Madden & Hirschman 2015), which can result in poor outcomes for residents if their express wishes 20 are not known to staff and / or family (Cagle et al, 2017). Having these conversations early in conjunction with current care preference discussions normalizes the EOL characteristic that can be uncomfortable, and allows the resident to express their fears, concerns, and desires related to EOL before it is happening. Despite the difficulty in initiating these conversations, it is important to have them to ensure resident preferences are known and accommodated to the best of the care team’s ability, to adhere to a personcentered model of healthcare. RECOMMENDATIONS Care Conferences in nursing homes are key meetings that afford residents an opportunity to convey their preferences and for staff to facilitate conversations about residents’ preferences among staff, residents and family members. My findings, specifically the answers to my objective questions and researched literature suggested the following recommendations to future team members involved in care conference meetings: 1. Incorporate either the Me & My Wishes video tool or a similar approach to encourage and facilitate difficult EOL and day-to-day preferences with residents. The response to the Me & My Wishes tool in care conferences was mostly favorable. In the sample I reviewed, the tool often led to meaningful discussion regarding resident preferences for care. 21 2. When reviewing the POLST form options with residents, review each option and give examples about what it entails so that residents are reliably informed each time their form is reviewed. POLST forms are composed of three parts: Cardiopulmonary Resuscitation (where individuals can choose either “attempt resuscitation” or “do not attempt resuscitation”), Medical Interventions (Comfort Measures, Limited Treatment, or Full Treatment) and Artificially Administered Nutrition (Long-term artificial nutrition through tubes, Defined trial period of artificial nutrition through tube, or No artificial nutrition trial period through tube) (National POLST Paradigm, 2019). Despite agreeing with the options that are provided on the POLST form, some residents didn’t seem to fully understand what the options entailed (e.g. “full treatment”, tube feeding trials, and intubation). Giving examples of each option and asking open-ended questions to the resident to identify specific POLST preferences is person-centered care because it ensures the resident is aware of their options and that they have had an opportunity to select their preferences in an informed way. 3. Include a brief discussion of the resident’s medical/social history each time a care conference is held, so that everyone can become oriented to and acquainted with the resident to ensure a person-centered care approach. Reviewing the resident’s history (including medical and social history) at each care conference ensures a person-centered care approach. Reviewing information that is unique to each resident puts each care team member on the same page regarding current status, and ensures the information discussed is individualized for each 22 resident. Making sure care conferences do not become routine in the sense that each resident’s conference is structured the same but allows for more individual approaches is critical to a person-centered care model (Håkansson Eklund et. al, 2019). In the current study, when patient history was discussed, it empowered residents to actively engage during the care conference, because it allowed them to contribute information that was unique to them, which, according to previous research, denotes a person-centered care approach (Puurveen, et. al 2018). 4. When unable to fulfill a resident request, continue to provide other opportunities and choices to allow the resident as much independence as possible. Throughout the care conferences that I reviewed, when resident requests (four in total) were not able to be implemented, the care teams endeavored to provide other options as similar to the original request as possible. While not always received happily from residents, these choices strived to include the resident as a part of a solution to the problem while also adhering to NH policy. For example, one resident missed her bird and the team conveyed to her that they were working to find a place the resident could move to that would allow her more access to her bird. Continuing to include the resident in these discussions despite barriers to preference incorporation is a wonderful person-centered care approach because the situation becomes more of a team effort towards solution rather than a compliance issue with the resident (Arora, et. al 2017). 23 5. Discuss psychosocial preferences (i.e. spiritual, social, and family preferences) surrounding end-of-life care. While advanced directives and POLST forms are excellent resources regarding medical care at the EOL, they are somewhat lacking in the psychosocial domain. My findings indicated that when the EOL was discussed during the care conference, it was mainly in reference to treatment preferences (e.g. CPR, or tube feeding). Conversations about spiritual preferences (e.g. last rites, clergy involvement, or musical hymns or prayers), or family involvement (e.g., what family would they want contacted, is there anybody they don’t want to be there, and are there any specific traditions that family needs to carry out) were not evident in the care conferences. Though questions of this nature are intimidating to ask, the content is crucial to ensuring a peaceful and person-centered passing of residents (Parry, et. al 2014; Towsley et. al, 2016). CONCLUSION Identifying the main topics addressed during care conferences gives a foundation for understanding how NHs can improve the incorporation of person-centered care, especially in reference to EOL conversations. The analyses done for this project identified primarily positive reactions to the Me & My Wishes video tool, which often resulted in more in-depth discussion, including discussions about EOL preferences. Continuing to ensure that the care conference is person-centered by including the resident and / or their family is imperative and both identifying and implementing their 24 preferences for both current care and EOL care will help to ensure that residents will have better health outcomes. NHs are in a unique position to uphold and encourage resident-centered care, and the place to start important conversations is within the care conference. 25 REFERENCES Arora, N. K., Gayer, C., DiGioia, K., Mason, N., Lawrence, W., Clauser, S. B., et al. (2017). A Patient-Centered Approach to Research on Palliative Care for Patients With Advanced Illnesses and Their Caregivers (Vol. 54, pp. e1-e9). New York, New York: Elsevier B.V. Brock, D. B., & Foley, D. J. (1998). Demography and epidemiology of dying in the U.S. with emphasis on deaths of older persons. The Hospice journal., 13(1-2), 49-60. Cagle, J. G., Unroe, K. T., Bunting, M., Bernard, B. L., & Miller, S. C. (2017). Caring for Dying Patients in the Nursing Home: Voices From Frontline Nursing Home Staff. Journal of Pain & Symptom Management, 53(2), 198-207. Hsieh, HF, Shannon SE: Three approaches to qualitative content analysis. Qual Health Res 2005; 15:1277–1288. (IOM), I. o. M. (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC. Håkansson Eklund, J. (2019). "Same or different?" A review of reviews of personcentered and patient-centered care. Patient education and counseling., 102(1), 3. Koren, M. J. (2010). Person-centered care for nursing home residents: the culture-change movement. Health affairs., 29(2), 312-317. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Final rule. (2016). Federal register., 81(192), 68688-68872. Miller, S. C., Lepore, M., Lima, J. C., Shield, R., & Tyler, D. A. (2014). Does the Introduction of Nursing Home Culture Change Practices Improve Quality? Journal of the American Geriatrics Society, 62(9), 1675-1682. Miller, S. C., Schwartz, M. L., Lima, J. C., Shield, R. R., Tyler, D. A., Berridge, C. W., et al. (2018). The Prevalence of Culture Change Practice in US Nursing Homes: Findings From a 2016/2017 Nationwide Survey. Medical Care, 56(12), 985-993. National POLST Paradigm. (2019). POLST Paradigm Form Elements. Retrieved from https://polst.org/about/polst-form-elements/ Older People Projected to Outnumber Children for First Time in U.S. History. (2018). census.gov 26 Parry R., Land V., & Seymour J. (2014). How to communicate with patients about future illness progression and end of life: a systematic review. BMJ Supportive & Palliative Care 2014; 4:331-341. Puurveen, G., Cooke, H., Rupali, G., & Jennifer, B. (2018). A Seat at the Table: The Positioning of Families During Care Conferences in Nursing Homes. The Gerontologist. The Number of Practicing Primary Care Physicians in the United States. (Page originally created September 2012. Content last reviewed July 2018). from http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html Towsley, G., Beck, S., Ellington, L., & Wong, B. (2016). Me & My Wishes. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 733464816657473. Towsley, G. L., Hirschman, K. B., & Madden, C. (2015). Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff. Journal Of Palliative Medicine, 18(5), 421–428. https://doi.org/10.1089/jpm.2014.0316 Towsley, and Hirschman. "Talking about End-of-life Care: Perspectives of Nursing Home Residents." Geriatric Nursing 39.1 (2017): 72-76. Web. Tyler, D. A., Shield, R. R., & Miller, S. C. (2015). Diffusion of palliative care in nursing homes: lessons from the culture change movement. Journal of Pain & Symptom Management, 49(5), 846-852. WHO Definition of Palliative Care. Retrieved from https://www.who.int/cancer/palliative/definition/en/ Table 1 Before and At the Time of Sharing the Me & My Wishes Videos Category Definition Exemplar Respectful interactions The resident was treated with respect by being introduced to team members and / or being called by their name vs. “he”, “she”, or “you” “Okay miss [RES name]. We sure care about you and we thank you.” “Okay [RES name]. Okay, how are things going right now?” 27 About the resident Discussed resident preference for current care Resident background information that was shared during the care conference, whether the information was medical history (including medication history), previous care preference documentation, or social history. “What does he have? Um, he has had a stroke. Oh, okay. When did he have the stroke?” What the resident wants for right now- whether they ask for food, treatment, activity or staffing changes, or affirm that their current care is where they want it to be. “You said that ‘the food is good most of the time’ but sometimes you wish you could have more desserts, right? Yes, all those pretty desserts – it’s just fruit, plain old glob of fruit cocktail.” “I have a social anxiety disorder” “I haven’t had a shower since last Thursday and it’s like I have to beat the barn down to get them to realize that I don’t get a shower only once a week… Discussed resident preference for end-of-life care Any reference to the end of life – whether that be advanced directives, family or spiritual traditions, or POLST form discussions. “So, I think we’re ready to move on to your code status. You’re full code – do you know what that means?” “Okay. And then on your POLST form, this is your physician orders, you’ve seen this, right? …Yes… So you will have CPR and you want full treatment? Do you still want that? …Yes.” 28 Resident/Family engagement during the care conference Whether the resident/family were engaged during the care conference. Labeled as “active engagement”, “passive engagement”, or “no engagement.” “I have an issue with therapy…Uh huh…And because of my recent little trip to the hospital-…Mhm…-I have a suspicion therapy may have inadvertently caused the uh, clot breakup… “ “Good. You feel like all your needs are being met?...Right, oh yeah…Do you have any concerns?...No…No? Okay.” Me & My Wishes Video Incorporation during the care conference For the care conferences that viewed the Me & My Wishes videos, the response was labelled “positive”, “neutral”, or “negative?” It was also identified when the video was shown, and whether conversations regarding video topics were had. Positive: “I’m so glad I got to watch this- more people should watch these.” Neutral: Conversation resumed where the care conference left off before watching the video. No direct comments made about the video. Negative: No exemplars from this study