PACE Intervention

Development of an intervention to integrate palliative care in care or nursing homes

PACE will (1) prepare a standardized intervention for six EU countries (BE, UK, IT, FI, PL, NL) via cross-cultural preparation and translation of the intervention and via feasibility testing in each country; (2) prepare the train-the-trainer guidelines and to organize a workshop for the training of the individual country trainers; (3) train country trainers responsible for implementation of the intervention in each country.
The intervention ‘Route to Success’ aims to integrate palliative care in day-to-day routines to ensure behavioral sustainability. At the core of the intervention is the nomination of a PACE coordinator in the long term care facility. All staff in the facility is supported by a Country Trainer who delivers workshops and provides support and education to all staff. In total the intervention consists of eight half day workshops which support and empower the PACE coordintor to implement and embed six steps within their facility. The six steps concern:


1. Discussions as the end of life approaches  Advance care planning discussions with residents and/or families to elicit wishes and preferences around end of life care. This communication process usually takes place in the context of an anticipated deterioration in the individual’s condition in the future, with attendant loss of capacity to make decisions and/or ability to communicate wishes to others
2. Assessment, planning and review  Completion of a prognostic register to prompt appropriate  advance care planning discussions, and do not attempt cardio-pulmonary resuscitation orders alongside regular symptoms assessments for pain, depression/anxiety and constipation
3. Co-ordination of care Monthly multidisciplinary review meetings where residents identified as having less than six months to live are discussed in detail, with specific invitations send to GPs
4. Delivery of high quality care in care homes General staff education concerning principles of palliative care for frail older people including those with dementia, symptom control and complex communication skills
5. Care in the last days of life Use of an integrated care plan for the last days of life to empower staff to provide high quality care to the dying resident and their family
6. Care after death Monthly reflective de-briefings groups to support staff following a death and encourage experiential learning


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