How to improve the care of elderly people residing in EHPAD: a mixed-methods interventional study on the value of an early integrated palliative approach.

The national context of the end of life of elderly people living in EHPAD is worrying.

A quarter of residents die every year, making up a quarter of annual deaths in France of all ages. Palliative care (PC), which is care focused on maintaining quality of life in the context of an incurable and complex pathology, therefore appears indicated in the context of EHPAD.

However, residents' access to SP, remains limited, uneven and delayed. The consequences of such a situation are far-reaching, firstly in terms of the quality of life of residents and their family carers, but also in terms of inappropriate use of healthcare services (as evidenced by excessive recourse to emergency departments and unscheduled hospitalizations) and quality of working life for carers (who suffer from a lack of support in the face of the difficulties of caring for residents at the end of life).

It's not just a question of the quality of life of residents and their family carers

The implementation of an early integrated palliative approach (DPIP) in the patient care pathway is one of the solutions recommended by the World Health Organization (WHO) and the Haute Autorité de Santé (HAS). Several studies have demonstrated the value of this approach to cancer care. However, the transferability and effectiveness of this approach (DPIP) in other organizational and population contexts, notably that of EHPADs, are poorly documented.

The PADI interventional research project aims to fill this gap through a participative approach involving co-construction, between care environment players (EHPAD, town, hospital) and researchers, of the integrated and early palliative approach with the aim of improving 1) residents' access to PH, 2) their quality of life and that of their loved ones, 3) the care pathway, and finally 4) should also improve professionals' quality of life at work. The project is based on a palliative approach model called "Démarche Palliative Intégrée et Précoce en EHPAD (DPIP-E). This model comprises two complementary axes: development of a shared vision of PH and organizational innovation facilitating the implementation of an early, integrated palliative approach.

The specific aims of the study:

The main objective is to evaluate, by means of a pragmatic controlled design, the effectiveness in the usual context of an integrated and early palliative approach on the adequacy of care for EHPAD residents requiring PH.

Secondary objectives:

The present project also investigates to what extent, how and under what conditions the implementation of an early, integrated palliative approach enables the adequacy of care for elderly residents of EHPAD whose state of health requires palliative care, as well as the conditions for transferability of the model tested.

This mixed-methodology interventional research, combining a quantitative multicenter interventional controlled study of the "stepped-wedge" cluster randomized trial type and a qualitative study of the multiple-case study type, will also focus on assessing the effects of the intervention on i) the quality of life of residents requiring PH and ii) that of their family caregivers, iii) on the quality of work life of caregivers and iv) on the care pathway of these same residents.

The total duration of this interventional research is four years. 21 EHPADs across 3 regions (Île-de-France, Nouvelle-Aquitaine and Provence-Alpes-Côte d'Azur) are participating.

This project will provide evidence on the value of the early integrated palliative approach and the conditions for its implementation and transferability. The proposed intervention will contribute to improving care practices for all participating EHPAD residents.