Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions

Factors Influencing Decision Making in Terminal Hospitalization of Nursing Home Residents: A Qualitative Study of the Perspective of Nurses, Social Workers, and General Practitioners

A significant percentage of nursing home residents die in hospitals. The objective of this study is to explore the factors that influence decision-making about hospitalizations of nursing home residents in the Czech Republic that become terminal. A total of 27 semi-structured interviews with nurses and social workers registered with nursing homes, as well as general practitioners cooperating with nursing homes, were conducted. Data were analyzed using thematic analysis. Six themes of the factors influencing decision-making about hospitalizations were made: the options of the nursing home, the accessibility of medical decision-making, inadequate care planning, the age of the resident, fear of legal action, and making the decision to hospitalize. Terminality of life seems to have no impact on the decision of nurses about hospitalization. Terminal hospitalization seems to be the result of the limited options that nurses have in different nursing homes in terms of how to organize end-of-life care.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study

Background

Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce.

Aims

The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer.

Methods

We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively.

Results

Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%).

Discussion

Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences.

Conclusion

Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01751-5) contains supplementary material, which is available to authorized users.

Who Doesn't Come Home? Factors Influencing Mortality Among Long-Term Care Residents Transitioning to and From Emergency Departments in Two Canadian Cities

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ² = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study

Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.

End-of-life nursing care practice in long-term care settings for older adults: A qualitative systematic review

AIM

To synthesize qualitative evidence on nurses' end-of-life care practices in long-term care settings for older adults.

BACKGROUND

Qualitative evidence on how nurses describe their own end-of-life care practice has not been reviewed systematically.

DESIGN

Qualitative systematic review.

DATA SOURCES

Databases MEDLINE, CINAHL, PsycINFO, EMBASE, Mednar, Google Scholar, and Ichushi were searched for published and unpublished studies in English or Japanese.

METHODS

The review followed the Joanna Briggs Institute approach to qualitative systematic reviews. Each study was assessed by two independent reviewers for methodological quality. The qualitative findings were pooled to produce categories and synthesized through meta-aggregation.

RESULTS

Twenty studies met all inclusion criteria. Their 137 findings were grouped into 10 categories and then aggregated into three synthesized findings: playing multidimensional roles to help residents die with dignity, needing resources and support for professional commitment, and feeling mismatch between responsibilities and power, affecting multidisciplinary teamwork.

CONCLUSION

Nurses play multidimensional roles as the health care professionals most versed in residents' complex needs. Managers and policymakers should empower nurses to resolve the mismatch and help nurses obtain needed resources for end-of-life care that ensures residents die with dignity.

Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty

Background

In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis.

Methods

To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature.

Results

Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies.

Conclusions

Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury.

Electronic supplementary material

The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.

Derivation and Confirmation of Scales Measuring Medical Directors’ Attitudes About the Hospitalization of Nursing Home Residents

Objectives: To derive and confirm scales measuring medical director’s attitudes about hospitalization of nursing home residents.

Method: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales.

Results: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations.

Discussion: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.

A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare

This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study ( n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008–2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.

Remaining in the nursing home versus transfer to acute care: resident, family, and staff preferences

Resident and family insistence on transfer is a major factor in the occurrence of potentially avoidable transfers from nursing homes (NHs) to acute care. The purpose of this study was to explore resident, family, and staff preferences regarding transfer to acute care. A sample of 271 NH residents, family members, staff, and medical providers were interviewed. Seventy-seven percent of residents reported that they had not given any thought to the question of whether they would want to be transferred to acute care. Family members wanted more information than residents, but more residents (39%) thought they should be fully involved in the transfer decision than their family members (12%) or staff (12%). Staff preferred keeping residents in the NH. Families were divided between transferring residents and having them remain in the NH. More residents indicated that their desire to transfer would depend on the severity of their condition and their prognosis. Ethnic group differences were noted. Results suggest that discussion of this issue should occur soon after admission and that differences in perspectives may be expected from those involved.

From nursing home to acute care: signs, symptoms, and strategies used to prevent transfer

Older adults are vulnerable to experiencing physiologic changes that may permanently decrease functional abilities when transferring from the nursing home (NH) to the acute care setting. Making the right decision about who and when to transfer from the nursing home (NH) to acute care is critical for optimizing quality care. The specific aims of this study were to identify the common signs and symptoms exhibited by NH residents at the time of transfer to acute care and to identify strategies used to prevent transfer of NH residents. Using survey methodology, this descriptive study found change in level of consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain were the highest ranked signs/symptoms requiring action. Actions to prevent transfer focused on stabilizing resident conditions and included hydration, oxygen, antibiotics, medications, symptom management, and providing additional physical assistance. When transfer was warranted, actions concentrated on the practical tasks of getting the residents transferred.

Nursing home characteristics associated with resident transfers to emergency departments

This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff--disproportionately present in publicly owned facilities--were associated with lower transfer rates. A number of other facility organizational characteristics--unrelated to ownership--were also associated with transfer rates.

Nursing home resident symptomatology triggering transfer: avoiding unnecessary hospitalizations

The purpose of this study was to describe nursing home resident symptomatology and medical diagnoses associated with nursing home to hospital transfers. A retrospective chart review of documented transfers was conducted at a 120-bed, nonprofit urban Continuing Care Retirement Center nursing home facility located in the southwestern United States. The transferred residents (n = 101) had seventy different medical diagnoses prior to hospital transfer with hypertension, coronary artery disease, and congestive heart failure most frequently reported. Most frequently reported symptomatology included fatigue, lethargy or weakness, shortness of breath, and change in level of consciousness. Multiple symptomatology was indicative of a wide variety of medical diagnoses. The diagnoses and symptomatology recorded in this paper identify the importance of strategic planning concerning assessment and communication of common nursing home resident symptomatology and the importance of basic nursing and diagnostic procedures for prevention of potentially avoidable hospitalizations.

Quality of care and quality of dying in nursing homes: two measurement models

BACKGROUND

There is consistent evidence of significant variation in the quality of end-of-life care among nursing homes, with many facilities ill-prepared to provide optimal physical and psychological care that is culturally sensitive and respectful of the needs and preferences of residents and their family members. There is continued evidence that what is impeding efforts to improve care is that most measurement tools are hampered by a lack of distinction between quality of care and quality of dying as well as a lack of complete psychometric evaluation. Further, health services researchers cite the need to include "system-level" factors, variables that reflect leadership, culture, or informal practices, all of which influence end-of-life care and can be used to differentiate one setting from another. The purpose of this article is to report advancement in conceptualizing quality end-of-life care in nursing homes and to offer a refined approach to measurement.

METHODS

Two latent constructs are tested: quality of care (composed of system-level factors) and quality of dying (comprised of resident/family outcomes). Data obtained from 85 Midwestern nursing homes and 1282 interviews with bereaved family members were used to evaluate both constructs.

RESULTS

Confirmatory factor analyses were conducted and evidence of validity and reliability were obtained for both.

CONCLUSION

For health services researchers, expanded models that include system-level factors as well as more comprehensive and psychometrically sound models of resident outcomes stand to inform efforts to improve care in this very important area.

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie.

The living-dying interval in nursing home-based end-of-life care: family caregivers' experiences

Guided by concepts from the living-dying interval ( Pattison, 1977 ) this study sought to explore family members' experiences with a dying nursing home resident. In-depth interviews were conducted with 31 caregivers of residents who had died. Interviews were audiotaped and transcribed. Themes that illuminated families' experiences on the living-dying interval were: an acute medical crisis (trigger events, accumulation of stressors, level of care crisis); the living-dying phase (advance care planning, hospitalization, end-stage decisions); and the terminal phase (beginning of the end, awareness of dying). The results illustrate critical periods for social work intervention with families of dying nursing home residents.

Decisions about transferring nursing home residents to hospital: highlighting the roles of advance care planning and support from local hospital and community health services

AIMS AND OBJECTIVES

To explore current practice and opportunities to improve practice in decision-making about transfer of nursing home residents to hospital.

BACKGROUND

Nursing home staff are often faced with the decision of whether to send a resident to hospital for medical treatment. While many residents will benefit from going to hospital, there are also several risks associated with this. This study sought to add to the existing body of research on this issue by seeking the views of nursing home managers, who are the persons most frequently involved in making these decisions.

DESIGN

Qualitative design using purposive, quota sampling.

METHOD

Qualitative interviews with 41 nursing home managers from south-western Sydney, Australia.

RESULTS

Factors affecting the decision to transfer a resident to hospital include acuteness of their condition; level and style of medical care available; role of family members; numbers, qualifications and skills mix of staff; and concern about criticism for not transferring to hospital. Two factors that have not featured as strongly in previous research are the roles of advance care planning and support from local hospital and community health services.

CONCLUSION

While transferring a nursing home resident to hospital is often necessary, there are many situations where they could be cared for in the nursing home; therefore, avoid complications associated with being in hospital. Apart from a range of factors already identified in the literature, this study has highlighted the important role that advance care planning and support from local health services can play in reducing unnecessary transfers to hospital.

RELEVANCE TO CLINICAL PRACTICE

There are several strategies that nursing homes and local health authorities can adopt to promote advance care planning and build better support systems between the two sectors, thereby reducing the numbers of residents who need to be transferred to hospital for their health care.

Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews

AIM

To explore the factors that influence the transfer of patients from residential aged care facilities (RACF) to hospital emergency departments (ED), and describe features of improved primary care in RACF that could result in reduced transfer.

METHODS

a. Three focus groups conducted with family and carers of RACF residents, along with RACF, ED and general practice staff. b. Semistructured one-on-one interviews with nine residents of RACF.

RESULTS

Five main themes emerged--staffing and skill mix in RACF, treatment options in RACF, end of life decision-making, communication and bureaucratic requirements. Analysis of the semistructured interviews demonstrated parallel concerns with many of the focus groups indicators. There was a strong but not universal preference among residents to minimise RACF to ED transfer.

CONCLUSIONS

The transfer of residents from RACF to ED is influenced by multiple interrelated factors, and strategies to reduce transfer should address these.

Predictors of nursing home hospitalization: a review of the literature

Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.

Decisions About Transfer From Nursing Home to Emergency Department

PURPOSE

To describe how decisions occurred to transfer nursing home (NH) residents to emergency departments (EDs).

DESIGN

Three nursing homes (NHs) in Virginia were selected based on geographic and ownership variability. The phenomenon of concern was the decision-making process culminating in the transfer of NH residents to EDs. Sixteen transfers met the inclusion criteria and were analyzed. A minimum of two informants per transfer were interviewed, with a range of 2 to 4 interviews per transfer. All 42 respondents were asked to describe how the transfer decision was reached, to identify who participated in making the decision, and to describe any particular positive or negative aspects of reaching the transfer decision.

METHOD

Data were analyzed with hermeneutic phenomenological methods. Journal writing, audit trails, informal and formal member checks, and expert consultation were used to control bias.

FINDINGS

The three main themes identified were Consensus, Conflict, and Cogency. Consensus, or agreement, occurred when all decision participants reported similar interpretations as to the severity and acuity of the presenting problem or had shared interpretations of the best interests of the elder. When decision participants held dissimilar interpretations, conflict occurred. Decision participants used cogency by persuading others, in order to reach consensus.

CONCLUSIONS

The findings cannot be generalized to long-term care facilities across the US or to other countries, but they enhance understanding about some of the ways transfer decisions occur and the role of nurses in those transfers, especially when conflict arises.

The challenge of providing palliative care in the nursing home

Nursing homes are increasingly becoming the place of care and site of death for growing numbers of frail older people dying of chronic progressive illnesses. Despite this increase, empirical evidence suggests that providing palliative care in nursing homes is replete with challenges. In a previous publication, the authors examined challenges external to the nursing home that influence the provision of palliative care, and which may be beyond the nursing home's control (Wowchuk et al, 2006). This paper reviews the primary internal factors identified in the literature that affect the provision of palliative care and are, to some extent, under the nursing home's control. The internal factors include: i) lack of care provider knowledge about the principles and practices of palliative care; ii) care provider attitudes and beliefs about death and dying; iii) staffing levels and lack of available time for dying residents; iv) lack of physician support; v) lack of privacy for residents and families; vi) families' expectations regarding residents' care; vii) hospitalisation of dying residents. Suggestions for practice, education and research are provided.

A survery of commitment and compassion among nurses in residential aged care

AIM

To assess the views and attitudes of aged care staff providing direct care towards palliative care and to identify their learning needs.

DESIGN

Survey design using purposive sampling methods.

FINDINGS

Nurses and care assistants (n=222) employed within nine residential aged care facilities in regional Australia completed the survey. The majority had received 'on the job training' and were committed to providing end-of-life care. Differences in the level of confidence to deal with patient/family interactions and manage complex palliative care scenarios were evident between nurses and care assistants (p<0.05). Both nurses and care assistants perceived a need for further education in symptom management and communication, yet their content need differed significantly between groups.

CONCLUSIONS

Nurses and care assistants in residential aged care facilities demonstrate commitment to the delivery of palliative care and express a need for increased palliative care competencies. The heterogeneity of roles and educational preparation within the aged care workforce indicate that tailored palliative care education initiatives are required to meet the learning needs of aged care nurses and care assistants, particularly in relation to end-of-life care. These data have implications for skill-mix and model of care development.

Death in the Nursing Home: Resident, Family, and Staff Perspectives

The actual experience of dying in the United States is far different from the expressed desires of most Americans. Although most Americans express a preference for dying at home, 73% of Americans die in medical institutions, with 23% dying in nursing homes (Teno, 2004). In this article, the author examines end-of-life care in the nursing home. A literature review identified more than 100 published articles relevant to end-of-life care in nursing homes. Of these, the author evaluated empirical research studies from the perspectives of residents, family members, and nursing home staff with findings specific to seriously ill nursing home residents. By identifying problematic issues and contributing factors, nurses can modify their practice to improve end-of-life care and substantially reduce suffering for nursing home residents and their families.

Do not hospitalize orders in nursing homes: a pilot study

OBJECTIVES

To determine (1) the point prevalence of do not hospitalize (DNH) policies in nursing facilities directed by members of the American Medical Directors Association (AMDA) Foundation Long-term Care Research Network, (2) the frequency with which physicians are writing DNH orders, and (3) respondent perceptions about the appropriateness of the number of DNH orders as too few or too many and reasons for such perceptions.

DESIGN

Online survey of members of the AMDA Foundation Long-term Care Research Network.

SETTING

Nursing facilities.

PARTICIPANTS

All members of the AMDA Foundation Long-term Research Network on July 1, 2003 were eligible for participation (N = 293).

INTERVENTION

None.

MEASUREMENTS

Demographic information regarding census, region, setting, governance, presence of teaching and/or hospice affiliation, prevalence of DNH orders, and qualitative information regarding the use of DNH orders in each facility.

RESULTS

The response rate was 32% (n = 95). DNH policies were in place for 62% of facilities and the prevalence of DNH orders ranged from 12% to 23% when facilities were stratified by size. Percentage of residents with documented DNH orders ranged from 0% to 99% at individual facilities. No significant differences were found although trends were noted as follows: chain facilities had fewer DNH policies (RR = 0.8; 95% CI = 0.6-1.1) whereas rural facilities (RR = 1.1, 95% CI = 0.8-1.5) and those associated with a teaching institution (RR = 1.1, 95% CI = 0.8-1.5) were more likely to have a DNH policy. Of respondents, 80% indicated that physicians in their facilities were writing DNH orders but 77% believed that the number of DNH orders was too few. Respondents cited overly optimistic prognosis and lack of knowledge about DNH orders as barriers to writing more DNH orders.

CONCLUSION

The prevalence of DNH orders in this investigation is higher than previous estimates from national data samples. Most facilities had a DNH policy and although respondents indicated that physicians do write DNH orders, they believed that DNH orders were not utilized frequently enough. There is a large variation in prevalence of DNH orders across the facilities included in this survey. Barriers to use, as perceived by medical directors, included unrealistic expectations by family, fear of litigation, and staff discomfort with managing residents who experience clinical decline. Nevertheless, DNH orders are used extensively in some facilities associated with members of the AMDA Foundation Long-term Care Research Network.

End-of-life care in U.S. nursing homes: a review of the evidence

OBJECTIVES

The purpose of this study was to systematically review the empiric evidence on end-of-life care in nursing homes in the United States The guiding research question for this review was what is the state of research evidence in end-of-life care in long-term care?

DESIGN

We conducted a systematic review of the literature.

DATA

The review was limited to published and indexed research in peer-reviewed journals in five major databases between 1995 and October 2002.

RESULTS

The initial search yielded a total of 395 articles. The search was narrowed, focusing on nursing homes in the United States and empiric research. The result was 43 articles related to research in end-of-life care in American nursing homes. It was categorized into eight foci: prognosis, pain, hospice, hospitalization, advanced care planning, communication, family perceptions, and miscellaneous.

CONCLUSION

There is a dearth of research published in end-of-life care in the nursing home setting. What is available is primarily descriptive. The empiric research only documents poor end-of-life care in U.S. nursing homes. Empiric evidence has grown in this area, but there is now a need for research of creative and innovative solutions aimed at improving the quality of end-of-life care in this setting.

The social, professional, and legal framework for the problem of pain management in emergency medicine

The problem of harmful, unnecessary and neglected pain has been studied extensively in many health care settings over the past decade. Research has documented the incidence of untreated pain, and scholars and advocates have given the problem several names: “public health crisis,” “oligoanalgesia, and “moral failing,” among them. Articles have identified a litany of now familiar “obstacles” or “barriers” to effective pain relief. Each of these individual obstacles or barriers has been the subject of targeted remedial action in at least some context.

The checklist approach to improving care for patients in pain, however, is likely to have only limited effect. What really appears to be operating is a complex ecosystem that supports ambivalence, denial, and even suspicion of the circumstance of patients in pain and efforts to treat them. Pain relief in emergency medicine, a relatively new setting for the study of challenges to treating pain, provides a revealing context for viewing discrete obstacles to effective pain management in medicine as part of an integrated environment into which patients with pain enter for treatment.

Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.