Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes

Citation: Mota-Romero, E.; Campos-Calderon, C.P.; Puente-Fernandez, D.; Hueso-Montoro, C.; Esteban-Burgos, A.A.; Montoya-Juarez, R. Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes. J. Clin. Med. 2022, 11, 5906. https://doi.org/10.3390/ jcm11195906 Academic Editors: Claudia Bausewein and Lukas Radbruch Received: 16 August 2022 Accepted: 1 October 2022 Published: 6 October 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Journal of Clinical Medicine Article Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes Emilio Mota-Romero 1,2,3,4 , Concepcion Petra Campos-Calderon 5, Daniel Puente-Fernandez 4,6,* , Cesar Hueso-Montoro 3,4,7 , Ana A. Esteban-Burgos 3,4 and Rafael Montoya-Juarez 3,4,7 1Dr. Salvador Caballero García Primary Care Centre, Andalusian Health Service, Government of Andalusia, 18012 Granada, Spain 2Doctoral Programme in Clinical Medicine and Public Health, University of Granada, 18071 Granada, Spain 3Department of Nursing, University of Granada, 18071 Granada, Spain 4Instituto de Investigación Biosanitaria, 18012 Granada, Spain 5Community Mental Health Unit, Andalusian Health Service, Government of Andalusia, 18800 Baza, Spain 6Department of Nursing, University of Jaen, 23071 Jaen, Spain 7Instituto Mente, Cerebro y Comportamiento (CIMCYC), University of Granada, 18016 Granada, Spain *Correspondence: [email protected]; Tel.: +34-958-248751 Abstract: The Nursing Homes End-of-life Programme (NUHELP) was developed in 2017 and is based on quality standards of palliative care, but it was not implemented due to the outbreak of the COVID-19 pandemic. Objectives: To describe perceptions among staff at nursing homes and primary health care (PHC) centres regarding the relevance, feasibility, and degree of achievement of quality standards for palliative care in nursing homes and to determine the differences in these perceptions before and after the pandemic. Methodology: Cross-sectional descriptive study. Professionals at eight nursing homes and related PHC centres who participated in NUHELP development assessed 42 palliative care standards at two time points (2018 and 2022). The Mann–Whitney U test was applied to analyse differences in the scores between these two times and between perceptions at nursing homes and at PHC centres. Results: The study population consisted of 58 professionals in 2018 and 50 in 2022. The standard regarding communication with persons affected by the death of a family member was considered less relevant (p= 0.05), and that concerning the culturally sensitive and dignified treatment of the body was less fully achieved (p= 0.03) in 2022 than in 2018. Social support (p= 0.04), sharing information among the care team (p= 0.04), patient participation (p= 0.04) and information about the treatment provided (p= 0.03) were all more poorly achieved in 2022 than in 2018. The perceptions of nursing home and PHC workers differed in several respects. Conclusions: Professional intercommunication and social support should be reinforced, and residents should be more actively involved in decision-making. Keywords: palliative care; palliative medicine; nursing homes; COVID-19; SARSCOV2; primary care 1. Introduction The global population is ageing. According to the World Health Organization, by 2050, there will be twice as many people aged over 65 as in 2019 (rising from 0.7 to 1.5 billion) [ 1 ]. By 2068, people aged over 65 years will constitute 29.4% of the Spanish population, compared to the 19.1% recorded in 2018 [ 2 ]. Spain will have the fourth highest ratio of dependency and of older people in the European Union [3]. In the future, there will be a greater need for caregivers for older people with chronic diseases. The ability of families to care for the elderly is conditioned by the transformation of family life, decreasing fertility and rising migration to urban areas, with the consequent geographical dispersion, among other factors [4]. In response to the foreseeable shortfall of informal caregivers, more older people will live in institutions. As an indication of this trend, the number of persons residing in nursing homes rose by 4.56% between 2015 and 2020 [5]. J. Clin. Med. 2022,11, 5906. https://doi.org/10.3390/jcm11195906 https://www.mdpi.com/journal/jcm J. Clin. Med. 2022,11, 5906 2 of 16 For many older people, nursing homes are their last place of life, and deaths in these institutions are expected to double by 2040 [ 6 ]. This outlook highlights the importance of the palliative care provided in nursing homes, where there is a high prevalence of chronic diseases [ 7 ]. An estimated 60–70% of chronic patients with palliative needs are residents in nursing homes [8]. Recent studies in Spain and the EU indicate that many residents of nursing homes receive unnecessary interventions at the end of life, such as cardiopulmonary resuscitation, mechanical ventilation, surgery, dialysis, blood transfusions, chemotherapy or radiotherapy [ 9 – 13 ]. The provision of high levels of medication is also common in the last weeks of life, and not all are related to symptom control [11,13]. Various institutions have emphasised the need for nursing home personnel to receive comprehensive training in end-of-life care [ 14 , 15 ] via programmes such as the Gold Standards Framework [ 16 ] or Namaste Care [ 17 ], which is specifically designed for nursing home residents with dementia. In Spain, a team of researchers from Granada and Jaén Universities developed the Nursing Home End of Life Programme (NUHELP) in 2017 to improve end-of-life care in nursing homes [18]. This programme is based on 42 standards for end-of-life care in adult palliative care units, published by the British National Institute for Health and Care Excellence [ 19 ] and the New Health Foundation [20]. These standards were evaluated in terms of their relevance, feasibility and degree of implementation at participating nursing homes and the health centres with which they were associated [18]. The COVID-19 pandemic provoked a radical change in the care provided by nursing homes, which were forced to adapt their internal operations in order to protect residents and staff from contagion [ 21 ]. Among the new measures adopted, family visits were restricted, access was controlled (with obligatory temperature testing and entry/exit registration), strict hand hygiene was required, the respiratory symptoms of staff and residents were assessed, and government-mandated protocols in response to positive contacts were applied [22]. Despite these measures, the mortality in nursing homes remains unacceptably high. In Spain, there have been 30,240 deaths from the SARS-CoV-2 virus in nursing homes since the start of the pandemic [ 23 ]. This mortality has been aggravated by demographic and healthcare-related factors (such as community life and the lack of personal protective equipment), regulatory and administrative factors regarding employment practices, and by factors related to comorbidity [24,25]. In view of these circumstances, the following question arises: do the staff at the nursing homes and primary health care (PHC) centres participating in the NUHELP programme attach the same value today as in 2018 to the quality standards then proposed for palliative care, or have their perceptions changed following the experience of the pandemic? Among the barriers to the provision of end-of-life care in nursing homes, responsibilities often remain unidentified, and coordination among the professionals involved is inadequate or non-existent [ 26 ]. Good communication is of vital importance, enabling mutual support between nursing home staff and those working in PHC [ 27 ]. Indeed, one of the strengths of the NUHELP programme is that it was designed jointly by nursing home and PHC personnel. However, there may be differences between these professionals in their perceptions of the quality of palliative care. The aims of this study are, on the one hand, to describe the relevance, feasibility and degree of achievement perceived by the nursing home and PHC staff of quality standards for palliative care in nursing homes before and after the COVID-19 pandemic and, on the other, to detect and identify any differences among the perceptions of those working in these two contexts. J. Clin. Med. 2022,11, 5906 3 of 16 2. Materials and Methods 2.1. Design This cross-sectional descriptive study was carried out at two time points (2018 and 2022). It cannot be considered a prospective study since the participants varied between the two periods. In the following sections, the participants and the data collection procedure are described for each time point considered. The instruments used and the data analysis procedures were identical in each case. 2.2. Sample The study was conducted among personnel at the eight nursing homes and PHC centres which collaborated in the development of the NUHELP programme. These institutions were chosen according to three criteria: • That the staff at the nursing homes and PHC centres involved were willing to participate in the development and subsequent implementation of the programme. • That the nursing homes had contracted with the local social services for the provision of assistance to the elderly. • That the nursing homes catered for at least 60 residents (this stipulation arose from the fact that centres of this size are required to have nursing staff on call 24 h a day and an in-house doctor). In 2018, an intentional sampling was carried out, recruiting 58 healthcare professionals (in the fields of nursing, medicine, social work and psychology) from nursing homes and PHC centres (medicine and nursing) associated with the NUHELP programme [18]. For the 2022 study, in addition to the aforementioned criteria, an additional requirement was included that the participants should have worked in these centres during the first waves of the COVID-19 pandemic (March–November 2020). 2.3. Data Collection Procedure In 2018, members of the NUHELP programme visited the participating centres to inform them of the Project’s aims and to request the participation of their staff. Once consent had been obtained, the project researchers contacted potential staff members by email, inviting them to return an online form. This data collection process took place from January to March 2018. In 2022, these same staff members were again contacted and asked to complete the same form again. In addition, the contact persons at each centre were asked to forward the form to other personnel who met the inclusion criteria and might be interested in taking part. This data collection process was carried out from January to March 2022. 2.4. Tools The questionnaire developed ad hoc for this study addressed the following sociodemographic and clinical variables: age, sex, professional category, employment pattern (full-time/part-time) and setting (nursing home/PHC centre). The questionnaire also included the 42 quality standards incorporated into the NUHELP programme, ordered by contextual relevance and detailed in Annex I. Each participant was asked to rate the standards according to the following criteria and scored on a Likert scale ranging from 1 (totally disagree) to 5 (totally agree). •Appropriateness of the care provided in the nursing home in question. •Feasibility of its implementation of palliative care. • Level of attainment, i.e., the extent to which the recommended palliative care was provided. The third criterion was only evaluated for the nursing homes since it was assumed that PHC personnel could not be expected to accurately determine this question for their place of work. J. Clin. Med. 2022,11, 5906 4 of 16 2.5. Statistical Analysis The continuous study variables were analysed using descriptive measures of central position and dispersion (mean and standard deviation) and the discrete variables by frequencies. The application of the Kolmogorov–Smirnov test showed that the responses to the different standards did not follow a normal distribution, and so the inferential analysis was performed by non-parametric tests. Two-tailed Mann–Whitney U and chi-square tests were performed to determine whether there were significant differences between the samples for the variables collected regarding both the time points considered (2018 and 2022) and the two groups of personnel (at nursing homes and PHC centres). 2.6. Ethical Considerations The study was approved by the Research Ethics Committee (0706-N-17). Information about the project was included in the online questionnaire. All of the participants provided prior informed consent and their contact information. At all times these data were separated from the questionnaire answers in order to protect the participants’ anonymity, in accordance with Organic Law 3/2018, of 5 December, on Personal Data Protection and Safeguards for Digital Rights [28]. 3. Results 3.1. Characteristics of the Sample In total, 108 healthcare personnel participated in the study, 58 (53.7%) in 2018 and 50 (46.3%) in 2022. Only ten of those who took part in 2018 repeated their participation in 2022. Most of the 2018 participants who did not repeat in 2020 (n= 35) were due to changes of workplace, either due to the impossibility to contact them (n= 3) or refusal to participate again (n= 2). The mean age of the participants in 2018 was 41 years ( SD = 10.7 ), while in 2022, it was 42 years (SD = 13.5). The total sample was composed of 84 women and 24 men. In 2018, these workers had overall professional experience and specific geriatric field experience of 10.9 years (SD = 8.4) and 11.2 years (SD = 7.7), respectively. In 2022, the corresponding figures were 11.3 years (SD = 7.8) and 14.2 years (SD = 9.78). The male:female ratio, the professional categories involved, the employment pattern and work settings were all similar at both time points. Table 1describes the demographic data of the sample in greater detail. Table 1. Characteristics of the Sample. 2018 (n= 58) 2022 (n= 50) p Age (years): 41 (10.7) 42(13.5) 0.49 * Professional experience (years): 10.9(8.4) 11.3(7.8) 0.45 * Geriatric care experience (years): 11.2(7.7) 14.2(9.78) 0.15 * Gender: Female 48 (82.8) 36 (72%) 0.25 ** Male 10 (17.2) 14 (28%) Qualification: Nurse 36 (62.1%) 37 (74%) Social worker 1 (1.7%) 2 (4%) Psychologist 9 (15.5%) 5 (10%) Physician 12 (20.7%) 4 (8%) Physiotherapist 2 (4%) Employment: Full time 48 (82.8%) 41 (82%) 0.918 ** Part time 10 (17.2%) 9 (18%) J. Clin. Med. 2022,11, 5906 5 of 16 Table 1. Cont. 2018 (n= 58) 2022 (n= 50) p Work setting: Nursing home 37(63.8%) 21(42%) 0.33 ** Primary care 21(36.2%) 29(58%) * Mann–Whitney U test. ** Chi-Square. 3.2. Differences in Palliative Care Standards between 2018 and 2022 According to Relevance, Feasibility and Level of Attainment With respect to the perceived relevance of palliative care standards, the participants awarded this criterion a score greater than four points (out of five) in both 2018 and 2022. The standard that received the highest score in 2018 was No. 40, “Communication with people greatly affected by the death of a family member is carried out in a sensitive manner” (4.71/0.59). In 2022, the highest score corresponded to No. 38, “The body of a person who has died is cared for in a culturally sensitive and dignified manner” (4.52/0.89). The lowest score in 2018 was for No. 32, “There is an education programme for patients and families who wish to use it, which facilitates decision-making throughout the course of the disease.” (3.97/1.15), while in 2022, it was for No. 14, “People approaching the end of life have their psychological needs safely, effectively, and appropriately met at any time of day or night, including access to medicines and equipment.” (3.94/1.24). Significant differences between the two time points were only found for No. 40, “Communication with people greatly affected by the death of a family member is carried out in a sensitive manner” (p= 0.05). In this case, the score in 2022 (4.44/0.81) was significantly lower than in 2018 (4.71/0.59). For the feasibility criterion, the highest-rated standard was No. 39, “Families and carers of people who have died receive timely verification and certification of the death.”, both in 2018 (4.64/0.61) and in 2022 (4.5/0.12). Those given the lowest scores were, in 2018, No. 32, “There is an education programme for patients and families who wish to use it, which facilitates decision-making throughout the course of the disease.” (3.24/1.23) and, in 2022, No. 2, “Generalist and specialist services providing care for people approaching the end of life and their families and carers have a multidisciplinary workforce sufficient in number and skill mix to provide high-quality care and support.” (3.30/1.16). Significant differences between the time points were only found for item No. 38, “The body of a person who has died is cared for in a culturally sensitive and dignified manner.” (p= 0.03), with significantly lower scores in 2022 (4.30/0.97) than in 2018 (4.62/0.77). With regard to the level of attainment, the highest rated standard in 2018 was No. 38, “The body of a person who has died is cared for in a culturally sensitive and dignified manner” (4.61/0.84), while in 2022, it was No. 39, “Families and carers of people who have died receive timely verification and certification of the death.” (4.24/1.08). The lowest rated standard was No. 32, “There is an education programme for patients and families who wish to use it, which facilitates decision-making throughout the course of the disease.”, both in 2018 (2.41/1.37) and in 2022 (2.60/1.34). For the level of attainment criterion, the scores for some standards were lower in 2022 than in 2018. This was the case for No. 15, “People approaching the end of life are offered social and practical support which is appropriate to their preferences and maximises independence and social participation for as long as possible.” (p= 0.045), No. 22, “Information about the patient is shared by all professionals involved in the care process.” (p= 0.044), No. 31, “The team enables the patient to be involved in decisionmaking throughout the course of the disease.” (p= 0.036) and No. 33, “The team provides information on the benefits and adverse effects of the treatments that may be provided to the patient.” (p= 0.026). Detailed results for these criteria are shown in Table 2. J. Clin. Med. 2022,11, 5906 6 of 16 Table 2. Differences in scores given by all participants between 2018 and 2022, according to relevance, feasibility and level of attainment. TOTAL 2018 n= 58 * 2022 n= 50 ** p*** M SD M SD 1 Health and social care workers have the knowledge, skills and attitudes necessary to be competent to provide high-quality care and support for people approaching the end of life and their families and carers. R 4.43 0.84 4.14 0.93 0.077 F 3.95 1.16 3.66 0.94 0.058 A 3.80 1.09 3.36 1.01 0.118 2 Generalist and specialist services providing care for people approaching the end of life and their families and carers have a multidisciplinary workforce sufficient in number and skill mix to provide high-quality care and support. R 4.38 0.91 4.00 1.18 0.096 F 3.45 1.16 3.30 1.16 0.519 A 3.50 1.09 2.96 1.16 0.147 3The roles and competencies of all professionals on the palliative care team are clearly defined. R 4.33 0.89 4.14 0.90 0.210 F 3.83 1.19 3.78 1.07 0.615 A 3.55 1.27 3.28 1.11 0.192 4The interdisciplinary team coordinates and works together on case conferences for each of the cases treated by the team. R 4.22 0.99 4.06 1.00 0.315 F 3.50 1.25 3.66 1.22 0.432 A 3.34 1.29 3.00 1.25 0.652 5 The criteria for referral to other professionals in the team/centre are clearly defined: criteria for care by the psychologist, criteria for care by the social worker, criteria for care by the counsellor or spiritual guide. R 4.33 0.82 4.06 1.02 0.188 F 3.83 1.11 3.54 1.16 0.208 A 2.72 1.90 3.12 1.21 0.367 6 The clinical material and medication needed to carry out care work are available to staff. R 4.29 0.99 4.36 0.94 0.780 F 3.71 1.11 3.96 1.09 0.194 A 3.61 1.02 3.70 1.15 0.409 7The meeting rooms, offices, etc. necessary for carrying out care activities are available to staff. R 4.47 0.78 4.32 0.91 0.456 F 4.34 0.87 4.12 1.06 0.285 A 4.20 0.95 3.82 1.12 0.113 8People approaching the end of life are identified in a timely manner. R 4.45 0.78 4.32 0.98 0.667 F 4.14 0.85 3.90 1.11 0.399 A 4.07 0.93 3.60 1.20 0.523 9 People approaching the end of life who may benefit from specialist palliative care are offered this care in a timely manner appropriate to their needs and preferences, at any time of day or night. R 4.33 0.96 4.24 0.98 0.553 F 3.74 1.04 3.56 1.07 0.387 A 3.57 1.02 3.06 1.10 0.134 10 People approaching the end of life are offered comprehensive assessments in response to their changing needs and preferences. R 4.33 0.89 4.16 1.00 0.387 F 4.02 0.91 3.76 1.08 0.256 A 3.55 1.07 3.26 1.12 0.514 11 Families and carers of people approaching the end of life are offered comprehensive assessments in response to their changing needs and preferences. R 4.17 0.94 4.14 0.93 0.824 F 3.67 1.10 3.56 1.07 0.664 A 3.36 1.12 3.00 1.25 0.488 12 The assessments made by the interdisciplinary team are continuously monitored. R 4.29 0.96 4.30 0.97 0.972 F 3.83 1.13 3.72 1.23 0.763 A 3.52 1.28 3.28 1.21 0.456 13 People approaching the end of life have their physical needs safely, effectively, and appropriately met at any time of day or night, including access to medicines and equipment. R 4.38 1.01 4.22 1.17 0.458 F 3.90 1.09 3.68 1.19 0.363 A 3.77 1.12 3.42 1.07 0.288 14 People approaching the end of life have their psychological needs safely, effectively, and appropriately met at any time of day or night, including access to medicines and equipment. R 4.14 1.08 3.94 1.24 0.421 F 3.48 1.11 3.32 1.27 0.631 A 3.27 1.15 2.84 1.28 0.246 15 People approaching the end of life are offered social and practical support which is appropriate to their preferences and maximises independence and social participation for as long as possible. R 4.16 1.04 4.06 1.04 0.561 F 3.69 1.17 3.52 1.09 0.383 A 3.52 1.23 3.06 1.11 0.045 J. Clin. Med. 2022,11, 5906 7 of 16 Table 2. Cont. TOTAL 2018 n= 58 * 2022 n= 50 ** p*** M SD M SD 16 People approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences. R 4.19 1.05 4.14 1.01 0.725 F 3.72 1.29 3.64 1.26 0.659 A 3.64 1.45 3.42 1.18 0.147 17 Families and carers of people approaching the end of life are offered comprehensive support in response to their changing needs and preferences. R 4.28 0.93 4.12 0.96 0.313 F 3.66 0.98 3.66 1.02 0.825 A 3.59 1.02 3.22 1.09 0.322 18 The team engages with family members in patients’ care. R 4.41 0.70 4.24 0.96 0.581 F 4.00 0.82 3.86 1.05 0.656 A 3.91 0.96 3.52 1.09 0.177 19 People approaching the end of life receive consistent care that is coordinated effectively across all relevant settings and services at any time of day or night. R 4.40 0.90 4.32 0.89 0.541 F 3.86 1.05 3.82 1.04 0.808 A 3.80 1.13 3.30 1.04 0.280 20 People approaching the end of life who experience a crisis at any time of day or night receive prompt, safe, and effective urgent care appropriate to their needs and preferences. R 4.47 0.90 4.32 0.96 0.345 F 4.19 1.00 3.86 1.05 0.070 A 3.98 1.11 3.56 0.99 0.098 21 The team uses clinical care protocols. R 4.41 0.84 4.38 0.81 0.715 F 4.05 0.89 4.18 0.90 0.411 A 3.77 1.01 3.68 1.10 0.855 22 Information about the patient is shared by all professionals involved in the care process. R 4.50 0.80 4.36 1.06 0.732 F 4.22 0.86 4.06 1.11 0.643 A 4.18 0.90 3.78 1.11 0.044 23 There is a procedure and utilisation rules in place for adding information to the clinical record. R 4.50 0.68 4.44 0.81 0.887 F 4.26 0.83 4.26 0.75 0.870 A 4.11 1.02 3.74 0.99 0.362 24 People approaching the end of life receive communication and information in an accessible and sensitive way in response to their needs and preferences. R 4.38 0.81 4.44 0.88 0.466 F 4.09 0.92 4.08 1.01 0.883 A 3.95 1.03 3.54 1.05 0.124 25 Families and carers of people approaching the end of life receive communication and information in an accessible and sensitive way in response to their needs and preferences. R 4.41 0.75 4.38 0.85 0.992 F 4.24 0.78 4.12 0.98 0.736 A 4.18 0.84 3.72 1.07 0.182 26 The professionals on the team safeguard the rights, responsibilities, and safety of the patient. R 4.50 0.76 4.44 0.79 0.676 F 4.29 0.82 4.20 0.99 0.817 A 4.25 0.89 3.88 1.00 0.193 27 The team informs both the patient and his or her legal guardian of the patient’s rights. R 4.34 0.85 4.22 1.02 0.634 F 3.93 1.01 3.92 1.18 0.776 A 3.80 1.15 3.48 1.07 0.217 28 The team has a statement of the rights and guarantees of patients and families available. R 4.26 0.83 4.16 0.98 0.775 F 3.88 1.11 3.96 1.03 0.748 A 3.43 1.23 3.36 1.06 0.821 29 A personalised care plan for people approaching the end of life which is appropriate to their needs and preferences is developed and reviewed. R 4.33 0.96 4.26 0.88 0.454 F 3.93 1.02 3.88 1.10 0.895 A 3.52 1.19 3.26 1.21 0.721 30 The professionals on the team ask the patient and family members how they would like to be informed about the diagnosis/prognosis/treatment progress of the disease and reflect this in the clinical record in a clearly visible place. R 4.28 0.95 4.20 1.11 0.876 F 3.88 1.14 3.94 1.20 0.664 A 3.73 1.26 3.38 1.19 0.100 31 The team enables the patient to be involved in decision-making throughout the course of the disease. R 4.47 0.92 4.32 1.02 0.272 F 4.07 1.02 4.02 1.10 0.921 A 3.91 1.18 3.54 1.22 0.036 J. Clin. Med. 2022,11, 5906 8 of 16 Table 2. Cont. TOTAL 2018 n= 58 * 2022 n= 50 ** p*** M SD M SD 32 There is an education programme for patients and families who wish to use it, which facilitates decision-making throughout the course of the disease. R 3.97 1.15 4.04 1.19 0.633 F 3.24 1.23 3.46 1.23 0.286 A 2.41 1.37 2.60 1.34 0.893 33 The team provides information on the benefits and adverse effects of the treatments that may be provided to the patient. R 4.57 0.75 4.26 1.07 0.107 F 4.29 0.86 4.10 1.11 0.493 A 4.07 1.09 3.68 1.10 0.026 34 There is an advance care directive document in place. R 4.19 1.18 4.14 1.31 0.915 F 4.05 1.30 3.78 1.47 0.325 A 2.95 1.55 3.18 1.32 0.894 35 Patient referral criteria are clearly defined. R 4.33 0.89 4.26 1.03 0.849 F 3.93 1.11 3.88 1.14 0.831 A 3.45 1.23 3.40 1.12 0.477 36 People approaching the end of life are identified in a timely manner and receive coordinated care according to a personalised care plan, including prompt access to comprehensive support, equipment, and medication management. R 4.57 0.73 4.32 1.02 0.247 F 4.12 0.94 4.02 1.08 0.748 A 3.95 1.01 3.60 1.12 0.422 37 Protocols and clinical guidelines for providing education and information about the dying phase to the family are available to the team. R 4.19 1.02 4.20 1.05 0.906 F 3.72 1.23 3.84 1.11 0.700 A 3.00 1.35 3.04 1.34 0.410 38 The body of a person who has died is cared for in a culturally sensitive and dignified manner. R 4.67 0.76 4.52 0.89 0.205 F 4.62 0.77 4.30 0.97 0.030 A 4.61 0.84 4.14 1.11 0.066 39 Families and carers of people who have died receive timely verification and certification of the death. R 4.67 0.60 4.50 0.84 0.379 F 4.64 0.61 4.50 0.84 0.512 A 4.59 0.69 4.24 1.08 0.481 40 People closely affected by a death are communicated with in a sensitive way. R 4.71 0.59 4.44 0.81 0.050 F 4.52 0.73 4.40 0.83 0.462 A 4.48 0.88 4.16 0.89 0.068 41 Protocols and clinical guidelines for providing grief care are available to the team. R 4.24 1.00 4.12 1.02 0.470 F 3.83 1.13 3.90 1.04 0.837 A 3.05 1.35 3.02 1.19 0.904 42 Families of the deceased are offered emotional and spiritual support appropriate to their needs and preferences during the grieving process. R 4.40 0.86 4.22 0.91 0.224 F 3.93 0.99 3.92 1.03 0.984 A 3.70 1.17 3.36 1.14 .087 * n = 37 level of attainment; ** n = 27 level of attainment; R: Relevance; F: Feasibility; A: level of attainment. *** Mann–Whitney U-Test. 3.3. Differences in Palliative Care Standards between Nursing Homes and Primary Health Care Professionals Some differences were observed in how health care professionals perceived the relevance and feasibility of the proposed standards according to their employment setting (nursing home or PHC centre) (Table 3). J. Clin. Med. 2022,11, 5906 9 of 16 Table 3. Scores given by nursing home (NH) and primary health care (PHC) professionals, according to relevance and feasibility. NH n= 64 PHC n= 44 p* M DS M DS 1 Health and social care workers have the knowledge, skills and attitudes necessary to be competent to provide high-quality care and support for people approaching the end of life and their families and carers. R 4.34 0.88 4.23 0.91 0.478 F 3.97 1.07 3.59 1.04 0.038 NH > PHC 2 Generalist and specialist services providing care for people approaching the end of life and their families and carers have a multidisciplinary workforce sufficient in number and skill mix to provide high-quality care and support. R 4.23 1.03 4.16 1.10 0.799 F 3.50 1.17 3.20 1.13 0.021 NH > PHC 3The roles and competencies of all professionals on the palliative care team are clearly defined. R 4.19 0.97 4.32 0.77 0.699 F 3.89 1.16 3.68 1.09 0.160 4The interdisciplinary team coordinates and works together on case conferences for each of the cases treated by the team. R 4.16 0.98 4.14 1.03 0.995 F 3.77 1.21 3.30 1.23 0.038 5 The criteria for referral to other professionals in the team/centre are clearly defined: criteria for care by the psychologist, criteria for care by the social worker, criteria for care by the counsellor or spiritual guide. R 4.23 0.92 4.16 0.94 0.610 F 3.91 1.06 3.39 1.19 0.021 NH > PHC 6The clinical material and medication needed to carry out care work are available to staff. R 4.22 1.03 4.48 0.85 0.240 F 3.67 1.22 4.05 0.86 0.160 7 The meeting rooms, offices, etc. necessary for carrying out care activities are available to staff. R 4.52 0.80 4.23 0.89 0.050 F 4.41 0.87 4.00 1.06 0.025 NH > PHC 8People approaching the end of life are identified in a timely manner. R 4.41 0.81 4.36 0.97 0.907 F 4.20 0.89 3.77 1.05 0.030 NH > PHC 9 People approaching the end of life who may benefit from specialist palliative care are offered this care in a timely manner appropriate to their needs and preferences, at any time of day or night. R 4.30 0.95 4.27 1.00 0.992 F3.77 1.07 3.50 1.02 0.144 10 People approaching the end of life are offered comprehensive assessments in response to their changing needs and preferences. R 4.25 0.96 4.25 0.92 0.873 F 4.05 0.97 3.68 1.01 0.051 NH > PHC 11 Families and carers of people approaching the end of life are offered comprehensive assessments in response to their changing needs and preferences. R 4.08 1.01 4.27 0.79 0.459 F3.75 1.05 3.43 1.11 0.135 12 The assessments made by the interdisciplinary team are continuously monitored. R 4.38 0.92 4.18 1.02 0.295 F 4.00 1.08 3.45 1.23 0.016 NH > PHC 13 People approaching the end of life have their physical needs safely, effectively, and appropriately met at any time of day or night, including access to medicines and equipment. R 4.25 1.10 4.39 1.06 0.454 F3.86 1.17 3.70 1.09 0.360 14 People approaching the end of life have their psychological needs safely, effectively and appropriately met at any time of day or night, including access to medicines and equipment. R 4.06 1.18 4.02 1.13 0.713 F3.56 1.14 3.18 1.23 0.097 15 People approaching the end of life are offered social and practical support which is appropriate to their preferences and maximises independence and social participation for as long as possible. R 4.14 1.02 4.07 1.07 0.705 F 3.89 1.03 3.20 1.17 0.002 NH > PHC 16 People approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences. R 4.22 1.00 4.09 1.07 0.543 F 4.00 1.11 3.23 1.36 0.003 NH > PHC 17 Families and carers of people approaching the end of life are offered comprehensive support in response to their changing needs and preferences. R 4.17 1.00 4.25 0.87 0.860 F 3.84 0.96 3.39 0.99 0.012 NH > PHC 18 The team engages with family members in patients’ care. R 4.31 0.81 4.36 0.87 0.576 F 4.00 0.94 3.84 0.91 0.339 J. Clin. Med. 2022,11, 5906 16 of 16 42. Miró,Ò.; Alquézar-Arbé, A.; Piñera, P.; Jacob, J.; Martín, A.; Llorens, P.; Jiménez, S.; González Del Castillo, J.; Gar-cía-Lamberechts, E.J.; Martín-Sánchez, F.J.; et al. Análisis de Los Protocolos y Recursos de Cuidados Críticos Para Pacientes Con COVID-19 Atendidos En Servicios de Urgencias Españoles En La Primera Ola Pandémica. Rev. Esp. Salud Publica 2021,95, e1–e16. 43. Köther, A.K.; Siebenhaar, K.U.; Alpers, G.W. Shared Decision Making during the COVID-19 Pandemic. Med. Decis. Mak. 2021,41, 430–438. [CrossRef] [PubMed] 44. Dhand, A.; Forman, L.; Vegunta, R.; Aronow, W.S.; Nabors, C. Challenges of Shared Decision Making in Older Patients with COVID-19. J. Am. Geriatr. Soc. 2020,69, 605–606. [CrossRef] [PubMed] 45. Guardia Mancilla, P.; Montoya-Juarez, R.; Marti-Garcia, C.; Herrero Hahn, R.; García Caro, M.P.; Cruz Quintana, F. Perceptions of health care professionals about end-of-life care, obstacles and ethical dilemmas in hospitals, primary care and nursing homes. An. Sist. Sanit. Navar. 2018,41, 35–46. [CrossRef] 46. Roscoe, L.A.; Hyer, K. Quality of Life at the End of Life for Nursing Home Residents: Perceptions of Hospice and Nursing Home Staff Members. J. Pain Symptom Manag. 2008,35, 1–9. [CrossRef] [PubMed]