The national context of the end of life of elderly people living in Nursing Home (NH) is
concerning.
A quarter of NH residents die each year representing a quarter of annual deaths in France of
all ages. The number of resident deaths arises (148,300 deaths in 2015 versus 124,500 in
2011). In fact, the age of residents welcomed in NH increase, 82% of residents are 80 years
old and over, suffering from several chronic pathologies, some of which are serious and
incurable. These are the main cause of death for residents. The advancing age of NH residents
and the interweaving of multiple chronic conditions and disabling pathologies generate
complex care needs, the complexity of which undermines the current system of care
organization. In 2016, 59% of NH residents were severely dependent in their activities of
daily living (ADL) and instrumental activities of daily living (IADL) according to the French
scale Autonomie, Gérontologie Groupe Iso Ressources, (1 the most dependant to 6 the less
dependent); the majority of these most dependent NH residents (80% of Groupe Iso-Ressource
1-2 in 2011) had at least one unstable chronic pathology and 73% of deceased residents (in
2015) come from this group whose level of dependence is very high.
Palliative care (PC), which is care focused on maintaining quality of life in a context of
incurable and complex pathology, therefore appears to be indicated in the context of NH.
However, residents' access to PC remains limited, uneven and late. The number of residents
requiring this support is estimated at more than 100,000 residents per year. The consequences
of such situation are serious, first with regard to the quality of life of NH residents and
their family caregivers, but also the inappropriate use of health services (as shown by the
excessive use of emergency department and unscheduled hospitalizations) and work life for
care providers in NH is affected (care providers suffer from a lack of support when faced
with the difficulties of caring for NH residents at the end of their life). However, these
consequences are potentially avoidable by means of adapted organizational solutions. The
implementation of an integrated and early palliative approach (IEPA) in care pathway of
patient is one of the solutions recommended by the World Health Organization and the French
National Authority for Health. Several studies have shown the benefit of such approach in the
management of cancer patients. However, the transferability and effectiveness of this
approach in other organizational and population contexts are poorly documented, particularly
in NH settings.
The main objective is to evaluate, through a pragmatic controlled trial the effectiveness of
an Early Integrated Palliative Care Approach in usual NH context (EIPCA-NH) on the quality of
care in NH for elderly in need of PC. The secondary objectives concern:
the implementation process of the EIPCA-NH: i) measure the degree of implementation of
the EIPCA-NH in each site, ii) identify and understand the factors (individual and
organizational) facilitating or limiting the success of the implementation process of an
IEPA according to NH contexts (inter-site comparison).
the effects of the EIPCA-NH in the NH : i) on the quality of life of residents requiring
PC and ii) that of their family caregivers, iii) on the quality work life of
professional caregivers and iv) on the care pathway of NH residents.
A mixed methods research, with qualitative and quantitative approach, will be carried out in
at least 20 NH in three different health territories. These NH will benefit from a EIPCA-NH
intervention which consists of 1) implementing a mechanism for sharing and co-producing
knowledge, 2) integrating this approach as early as possible in the care of residents. This
study is based on a multicenter, randomized crossover cluster-type stepped-wedge study,
running on 4 years in order to measure the sustainability of EIPCA-NH; the quantitative
analysis of the effectiveness of EIPCA-NH will focus on an open cohort of 3,500 residents
receiving the intervention. The qualitative component will consist of a multiple case study
to analyse the process of implementation and production of the EIPCA-NH. The integrative
analysis of qualitative and quantitative data will allow a better understanding of the causal
mechanisms of the observed phenomena.
This project will provide evidence on the value of EIPCA and the conditions for its
implementation and transferability. The proposed intervention will help improve care
practices for all NH residents (600,000 people). The approach by co-construction between
actors of the thousands of care structures (NH, cities, hospitals) and researchers should
promote a better representation of PC, promote the culture of anticipation, evaluation and
collaboration between actors of in- and out- NH, contributing to a better synergy of
intersectoral and territorial actions of the supply of health services.