The challenges and opportunities in providing end-of-life care in nursing homes

Dying in a nursing home: the role of local bed supply in nursing home discharges

OBJECTIVE

The relationship of nursing home (NH) discharges due to death to NH bed supply and hospital bed supply was examined.

METHOD

Data on discharges came from the 1999 National Nursing Home Survey (N = 6,335). County-level bed supply, controls for hospice agency supply, and a nursing facility's percentage of area NH beds came from the Area Resource File. Multinomial logistic regression was used to compare deaths with live discharges. Marginal effects were calculated.

RESULTS

Discharges due to death increased with increasing NH bed supply and decreased in areas with greater hospital bed supply, areas where hospitalizations were more likely. Hospice supply and a facility's share of area NH beds also affected the probability of discharges due to death.

DISCUSSION

Supply factors appear related to discharge decisions in a manner affecting the probability of discharges due to death, although the magnitude of the relationship may be less than expected.

The pain of residents with terminal cancer in USA nursing homes: family members' perspectives

Cancer pain continues to be poorly treated despite efforts aimed at improvement. This causes considerable distress to both patients and their families. The purpose of this research is to explore the perspectives of family members of nursing home residents with terminal cancer, about pain and pain management. Participants who believed their pain could be better managed viewed their family member's pain and illness differently than those who believed the pain could not be managed better. The family members who believed better pain management was possible often took on the role of advocate and saw to it that the pain was addressed. Those who believed that their relative did not have adequate pain relief, but felt better management was not possible, expressed no concerns about this aspect of their relatives' care; they could not separate their relatives' pain from their illness. The interpretation and presence of adequate pain management is critical for family members to construct meaning around their relative's pain. When family members do not believe that the pain can be managed any better, this acts as a barrier to the resident's access to adequate pain management.

Palliative care services in Pennsylvania nursing homes

BACKGROUND

Palliative care is an interdisciplinary model that focuses on the comprehensive management of physical, psychological, social, and spiritual needs of individuals with lifelimiting illness. Although palliative care is increasingly common in acute care settings, regulatory, financial, and educational barriers often bar nursing home residents from access to palliative care services.

OBJECTIVE

The purpose of the Palliative Care Services in Pennsylvania Nursing Homes Survey was to describe existing palliative care services within nursing homes in Pennsylvania, and to classify these services by level of care delivery.

METHODS

Ninety-one nursing home administrators throughout the state of Pennsylvania participated in the mailed survey. Multiple logistic regression analysis was used to investigate the association between various organizational characteristics and provision of palliative care services.

RESULTS

Results reveal that urban facilities were more likely to provide palliative care services than rural facilities. Urban facilities cited the need for bereavement training most frequently, whereas rural clinical cited the need for training in pain management. Larger facility size was associated with an increased likelihood of pain management practices, even after adjusting for regional differences.

CONCLUSIONS

These pilot findings are consistent with and extend previous findings suggesting that palliative care practice in nursing homes is strongly influenced by nonclinical factors and invites further investigation.

Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations

The Resource Center of the American Alliance of Cancer Pain Initiatives provided templates, faculty, and ongoing consultation to assist seven state pain initiatives to implement programs to improve pain management practices. A total of 113 health care organizations participated. Each organization committed to support a team of two to three staff through a 10-month pain quality improvement process, which included a site visit, two educational conferences, pre- and postprogram analyses of the organizational structures in place to support pain assessment and management, quality improvement work plan development, and patient survey data collection. Postprogram results showed statistically significant increases in the presence of structural elements that are critical to effective pain management, as well as statistically significant, though modest, decreases in the percentage of patients who reported pain of any severity, and specifically moderate to severe pain, in the previous 24 hours. The largest changes occurred in long-term care facilities. Nevertheless, the percentage of patients in moderate to severe pain remained unacceptably high.

Physicians "missing in action": family perspectives on physician and staffing problems in end-of-life care in the nursing home

OBJECTIVES

To understand the roles of physicians and staff in nursing homes in relation to end-of-life care through narrative interviews with family members close to a decedent.

DESIGN

Qualitative follow-up interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants.

SETTING

Brown University interviewers conducted telephone interviews with participants throughout the United States.

PARTICIPANTS

The 54 participants agreed to a follow-up qualitative interview and were family members or close to the decedent.

MEASUREMENTS

A five-member, multidisciplinary team to identify overarching themes taped, transcribed, and then coded interviews.

RESULTS

Respondents report that healthcare professionals often insufficiently address the needs of dying patients in nursing homes and that "missing in action" physicians and insufficient staffing create extra burdens on dying nursing home residents and their families.

CONCLUSION

Sustained efforts to increase the presence of physicians and improve staffing in nursing homes are suggested to improve end-of-life care for dying residents in nursing homes.

Analyses of nursing home residents with cancer at admission

The objective of the study was to profile nursing home residents with cancer at admission to the nursing facility. We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 61,890 residents with cancer, or 11.3% of all admissions. Nursing home residents with cancer were significantly older and more likely to be male than other residents at admission. Large proportions of nursing home residents with cancer were activities of daily living dependent and about 55% used a wheelchair as their primary mode of locomotion. More than 37% of residents with cancer experienced at least moderate daily pain at admission and almost 26% had a diagnosis of depression. At admission, more than half of residents with cancer had an unstable health condition, 21% were judged to be in their final 6 months of life, and 19% received hospice care. More than 40% of residents with cancer had no advance directives recorded at admission. Compared to other residents at admission, larger proportions of residents with cancer require heavy care. Staff at nursing facilities need to address depression, pain management, and the implementation of advance directives to improve the quality of life for residents with cancer.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Identifying educational needs in end-of-life care for staff and families of residents in care facilities

AIM

the purpose of this article is to describe educational needs in end-of-life (EoL) care for staff and families of residents in long-term care (LTC) facilities in the province of Ontario, Canada. Barriers to providing end-of-life care education in LTC facilities are also identified.

DESIGN, SETTING AND PARTICIPANTS

cross-sectional survey of directors of care in all licensed LTC facilities in the province of Ontario, Canada.

RESULTS

directors of care from 426 (76.9% response rate) licensed LTC facilities completed a postal-survey questionnaire. Topics identified as very important for staff education included pain and symptom management and communication with family members about EoL care. Priorities for family education included respecting the residents' expressed wishes for care and communication about EoL care. Having sufficient institutional resources was identified as a major barrier to providing continuing education to both staff and families.

CONCLUSION

through examining educational needs in EoL care this study identified an environment of inadequate staffing and over-burdened care providers. The importance of increased staffing concomitant with education is a priority for LTC facilities.

Palliative Care NURSING EDUCATION: OPPORTUNITIES FOR GERONTOLOGICAL NURSES

Approximately 80% of Americans who die each year are 65 or older. Increasingly, gerontological nurses are asked to deliver high quality end-of-life care. Studies, however, have identified deficiencies in the delivery of care to older adults who are dying-particularly those who die in nursing homes. Enhancing nursing education and training in end-of-life care is one strategy proposed as a remedy for inadequate care for nursing home residents who are dying. This article reviews the current status of end-of-life nursing home care, describes the philosophy and components of quality palliative care, and provides information about opportunities and resources for educating gerontological nurses in end-of-life care.

Enhancing End-of-Life Care in Nursing Homes: Palliative Care Educational Resource Team (PERT) Program

BACKGROUND

By the middle of this century, approximately 40% of people who will die from chronic illness are expected to do so in a nursing home. This trend will create challenges for nursing homes to ensure that staff possess the necessary knowledge and skills to care for dying residents.

OBJECTIVE

The purpose of this paper is to describe the development and evaluation of a comprehensive curriculum called Palliative Care Educational Resource Team (PERT), which is designed to enhance end-of-life (EOL) abilities of nursing assistants and licensed nurses working in nursing homes.

SUBJECTS

Sixty-one nursing assistants and 108 licensed nursing staff from 44 facilities have participated in PERT. Subjects were recruited in three successive cohorts, each targeting a different geographic area.

MEASUREMENTS

Program evaluation included multiple tools evaluating participants' knowledge, skills, and confidence in providing EOL care.

RESULTS

Evaluation of outcomes revealed significant increases in EOL knowledge, self-evaluation of EOL skills, and supervisors' evaluations of participants' EOL care.

CONCLUSIONS

These results show that the PERT Program is an effective means to enhance the palliative care expertise of nursing home staff. In addition to describing the PERT program and its evaluation, suggestions for implementing similar programs are included in this paper.

Hospice and palliative care in nursing homes

This article reviews the challenges inherent in providing high-quality palliative care to dying nursing home residents and summarizes the efforts to address these challenges. It is suggested that a stronger physician presence and oversight of physicians knowledgeable in palliative care in nursing homes are needed to improve the quality of end-of-life care in nursing homes.

Factors Influencing Models of End-of-Life Care in Nursing Homes: Results of a Survey of Nursing Home Administrators

Approximately 20% of deaths in the United States occur in nursing homes. Dying nursing home residents have unique care needs, which historically have been inadequately addressed. The goal of this study was to determine what factors influence nursing home administrators' choice of model for end-of-life care in their facilities. Thirty nursing home administrators in the Denver, Colorado, metropolitan area were interviewed. The interview used open-ended questions about: facilities' end-of-life care programming and factors that influenced which model was used; scalar questions measuring administrators' attitudes about aspects of end-of-life care; and questions that assessed key demographic characteristics of participants. Twenty-nine of the 30 facilities included in this study reported contracting with hospice. Five were also in the process of creating in-house palliative care teams, and an additional five were negotiating with hospice agencies to dedicate beds for use as hospice units. For profit status, larger facility size, and shorter duration of administrator tenure were found to be associated with greater likelihood of considering implementation of a facility-based end-of-life care model. When asked about obstacles to providing quality end-of-life care, the majority of participants (n = 16) cited an educational deficit among physicians, staff, or the public as the most significant, while an additional seven cited staff shortages and turnover. These results suggest at least two potential avenues for change to improve end-of-life care in nursing homes: (1) educational efforts on the topics of end-of-life and palliative care among both practitioners, residents, and their families, and (2) creating incentives to improve staff recruitment and retention.