Abstract
BACKGROUND: Although a palliative approach to care is recommended for people with advanced dementia, many nursing home (NH) residents with dementia experience burdensome interventions such as hospital transfers at the end of life. OBJECTIVE: The goal of this study was to examine how decisions to transfer NH residents with advanced dementia are made, from the perspective of NH nurses and physicians. METHODS: A qualitative, descriptive method was used. Purposive sampling was used to recruit 20 healthcare providers from 9 NHs. Data collection included semistructured, open-ended interviews. RESULTS: Decision making regarding hospital transfer comprised two phases. Phase one, laying the groundwork, was influenced by the ability of the providers to effectively establish trust, foreshadow, and illuminate hazards of hospitalization. Phase two, responding to an acute event, began at the start of an acute event and ended when a decision was made to either treat the resident in the NH or transfer to the hospital. Responding to the acute event was influenced by the ability to care for residents in the NH, the providers' comfort with end-of-life conversations, and surrogates' preferences. CONCLUSIONS: Advance care planning before an acute event is only the first step in a process of decision making. Attention to and support for decision making is needed at the time of each acute event to ensure that goals of care are maintained.