At least one out of every four Americans dies in a nursing home. Unfortunately, evidence indicates that nursing home residents do not receive the best end-of-life care, and relatives are often unhappy with the quality of end-of-life care their loved ones receive in nursing homes.
One problem associated with nursing homes is inadequate pain management. Another is that most nursing home residents are transferred to an acute-care setting during the last weeks of life where they receive aggressive (and sometimes unwelcome) treatment to prolong life.
Hospice is a philosophy of care that emphasizes quality, rather than length, of life. Hospice care can take place in a hospital, nursing home, or in a patient or caregiver’s home, and it is appropriate when a patient is not expected to live longer than six months. The goal of hospice is to allow patients to be alert and pain- and symptom-free at the end of life.
At present, only one in four nursing home residents enroll in hospice care. Although hospice isn’t the right choice for everyone, research has suggested that more nursing home residents and their families could benefit from hospice care.
In a study published in the July 13, 2005
Journal of the American Medical Association
, researchers sought to determine whether more nursing home residents would enroll in hospice care if their physicians were aware of their end-of-life goals and preferences. They found that nursing home residents who were identified to their physicians as appropriate for hospice care (and who then received a hospice information visit) were significantly more likely to enroll in hospice care than those whose physicians were not contacted. In addition, the families of residents who had been informed about hospice care rated their loved ones’ end-of-life care significantly higher than families of residents who were not informed.
The researchers recruited 205 residents from three nursing homes. All of the residents and/or their surrogate decision makers (such as a family member) were asked scripted interview questions to determine whether the residents were appropriate for hospice care. The researchers considered the residents to be appropriate for hospice care if either the resident or their surrogate:
Expressed that comfort was a priority for their care;
Refused CPR or mechanical ventilation; and
Identified the need for additional support such as nursing or emotional support.
The researchers then randomly assigned 107 residents to the intervention group and 98 residents to the control (usual care) group.
For the intervention group, if the resident met the criteria for hospice care, the researchers notified the resident’s physician by fax. If the resident was expected to live for six months or less, the physician was asked to authorize a hospice information visit.
For the control group, residents who met the criteria for hospice care were given a brief description of hospice and were told they could learn more about it by speaking with their physician. However, the resident’s physicians were not contacted by the researchers.
All residents were followed up for six months or until they died. After death, the resident’s surrogates rated the care the resident received in their final week of life.
Thirty-five of the 107 residents in the intervention group were deemed to be appropriate for hospice care versus 49 of the 98 residents in the control group. Thirty days into the study, however, only one of the 98 residents in the control group (1%) was enrolled in hospice care versus 21 of the 107 residents in the intervention group (20%). This was a significant difference.
By the end of the six-month follow-up period, residents in the intervention group were still significantly more likely to have enrolled in hospice (25% versus 6%). During this period, intervention residents also had significantly fewer admissions into an acute care facility and spent significantly fewer days in an acute care setting.
A total of 23 residents died during the six-month follow-up. Although intervention residents received significantly more days of hospice care than usual care residents (64 days versus 14 days), they were not more likely to be enrolled in hospice at the time of their death. Residents in both the intervention and control groups who were enrolled in hospice care were significantly more likely to die in a nursing home than in an acute care setting.
Finally, the surrogate’s ratings for the quality of care their loved one received in the last week of life were significantly higher in the intervention group than the control group (4.3 versus 2.2 on a scale of 1 to 5 with 1 being “poor” and 5 being “excellent”). Residents who were enrolled in hospice longer had higher quality of care ratings than those with shorter enrollment prior to death.
One limitation to this study was that the researchers did not observe the care the residents received during the follow-up. As a result, it is not possible to determine how hospice enrollment changed the care the residents were receiving, and whether hospice was entirely responsible for the surrogate’s ratings or for the reduction in acute care admissions.
This study demonstrated that nursing home residents whose physicians were made aware of their appropriateness for hospice were significantly more likely to enroll in hospice care. In this case, a simple, low-cost strategy had a profound financial (fewer days in an acute care setting) and personal (higher surrogate ratings of quality of end-of-life care) impact.
The intervention involved only three steps: 1) identifying residents appropriate for hospice care 2) letting physicians know about patients who were appropriate for hospice 3) arranging a hospice information visit.
In this study, a five to ten minute interview was all it took to determine whether a nursing home resident was appropriate for hospice care. According to the researchers, a scripted interview such as the one used in this study, could be administered by anyone on a health care team, with minimal training. Once the physicians were made aware of their patient’s end-of-life objectives, nearly three-quarters authorized a hospice information visit, leading to 20% hospice enrollment within 30 days. Each of the nursing homes studied had already developed its own hospice program (or a formal affiliation with an outside hospice) prior to the study. The results of this study might not apply to nursing homes that have no such hospice affiliation.
Physicians, nursing home staffs, and other health care professionals who deal with older adults should take the time to introduce the idea of hospice to their patients. Hospice can improve the end-of-life experience for appropriate nursing home residents and their families—with the added bonus of limiting the skyrocketing costs associated with end-of-life care. For those nursing home residents who meet hospice admission requirements, earlier enrollment in hospice programs may lead to greater satisfaction with care when family members (surrogates) are interviewed several months following death.