Indicators of quality medical care for the terminally ill in nursing homes

Pressure Ulcer Prevention and Treatment in Hospices: A Qualitative Analysis

There has been little research into pressure ulcer prevention and treatment in hospices. In this study, interviews with hospice directors of clinical services and direct-care nurses were analyzed using qualitative methods. Several general themes were found. Both pressure ulcer prevention and treatment can be painful to hospice patients. Comfort may supersede prevention and wound care when patients are actively dying or have conditions causing them to have a single position of comfort. Family caregivers must face additional burdens when a pressure ulcer develops. In conclusion, hospice providers, patients, and family caregivers together must balance patient comfort with pressure ulcer prevention and treatment, which often leads to decisions to accept death with a pressure ulcer. Future studies should clarify how these parties can best work together, especially to identify when prevention or treatment has become futile.

Systematic Quality Monitoring For Specialized Palliative Care Services: Development of a Minimal Set of Quality Indicators for Palliative Care Study (QPAC)

Background:

A feasibility evaluation of a comprehensive quality indicator set for palliative care identified the need for a minimal selection of these indicators to monitor quality of palliative care services with short questionnaires for the patients, caregivers, and family carers.

Objectives:

To develop a minimal indicator set for efficient quality assessment in palliative care.

Design:

A 2 round modified Research ANd Development corporation in collaboration with the University of California at Los Angeles (RAND/UCLA) expert consultation.

Setting/Patients:

Thirteen experts in palliative care (professionals and patient representatives).

Measurements:

In a home assignment, experts were asked to score 80 developed indicators for “priority” to be included in the minimal set on a scale from 0 (lowest priority) to 9 (highest priority). The second round consisted of a plenary meeting in which the minimal set was finalized.

Results:

Thirty-nine of the 80 indicators were discarded, while 19 were definitely selected after the home assignment, and 22 were proposed for discussion during the meeting; 12 of these survived the selection round. The final minimal indicator set for palliative care consists of 5 indicators about the physical aspects of care; 6 about the psychosocial aspects of care; 13 about information, communication, and care planning; 5 about type of care; and 2 about continuity of care.

Conclusion:

A minimal set of 31 indicators reflecting all the important issues in palliative care was created for palliative care services to assess the quality of their care in a quick and efficient manner. Additional topic-specific optional modules are available for more thorough assessment of specific aspects of care.

Consensus on quality indicators to assess the organisation of palliative cancer and dementia care applicable across national healthcare systems and selected by international experts

Background

Large numbers of vulnerable patients are in need of palliative cancer and dementia care. However, a wide gap exists between the knowledge of best practices in palliative care and their use in everyday clinical practice. As part of a European policy improvement program, quality indicators (QIs) have been developed to monitor and improve the organisation of palliative care for patients with cancer and those with dementia in various settings in different European countries.

Method

A multidisciplinary, international panel of professionals participated in a modified RAND Delphi procedure to compose a set of palliative care QIs based on existing sets of QIs on the organisation of palliative care. Panellists participated in three written rounds, one feedback round and one meeting. The panel’s median votes were used to identify the final set of QIs.

Results

The Delphi procedure resulted in 23 useful QIs. These QIs represent key elements of the organisation of good clinical practice, such as the availability of palliative care teams, the availability of special facilities to provide palliative care for patients and their relatives, and the presence of educational interventions for professionals. The final set also includes QIs that are related to the process of palliative care, such as documentation of pain and other symptoms, communication with patients in need of palliative care and their relatives, and end-of-life decisions.

Conclusion

International experts selected a set of 23 QIs for the organisation of palliative care. Although we particularly focused on the organisation of cancer and dementia palliative care, most QIs are generic and are applicable for other types of diseases as well.

Improving national hospice/palliative care service symptom outcomes systematically through point-of-care data collection, structured feedback and benchmarking

Purpose

Every health care sector including hospice/palliative care needs to systematically improve services using patient-defined outcomes. Data from the national Australian Palliative Care Outcomes Collaboration aims to define whether hospice/palliative care patients’ outcomes and the consistency of these outcomes have improved in the last 3 years.

Methods

Data were analysed by clinical phase (stable, unstable, deteriorating, terminal). Patient-level data included the Symptom Assessment Scale and the Palliative Care Problem Severity Score. Nationally collected point-of-care data were anchored for the period July–December 2008 and subsequently compared to this baseline in six 6-month reporting cycles for all services that submitted data in every time period (n = 30) using individual longitudinal multi-level random coefficient models.

Results

Data were analysed for 19,747 patients (46 % female; 85 % cancer; 27,928 episodes of care; 65,463 phases). There were significant improvements across all domains (symptom control, family care, psychological and spiritual care) except pain. Simultaneously, the interquartile ranges decreased, jointly indicating that better and more consistent patient outcomes were being achieved.

Conclusion

These are the first national hospice/palliative care symptom control performance data to demonstrate improvements in clinical outcomes at a service level as a result of routine data collection and systematic feedback.

Quality indicators for palliative care: update of a systematic review

CONTEXT

In 2007, a systematic review revealed a number of quality indicators referring mostly to palliative care outcomes and processes. Psychosocial and spiritual aspects were scarcely represented. Most publications lacked a detailed description of the development process. With many initiatives and further developments expected, an update is needed.

OBJECTIVES

This update gives an overview of the published quality indicators for palliative care and identifies any new developments since 2007 regarding the number and type of indicators developed and the methodology applied.

METHODS

The same literature search as in the 2007 review was used to identify relevant publications up to October 2011. Publications describing development processes or characteristics of quality indicators for palliative care were selected by two reviewers independently.

RESULTS

The literature search resulted in 435 hits in addition to the 650 hits found in the previous review. Thirteen new publications were selected in addition to the 16 publications selected earlier, describing 17 sets of quality indicators containing 326 indicators. These cover all domains of palliative care as defined by the U.S. National Consensus Project. Most indicators refer to care processes or outcomes. The extent to which methodological characteristics are described varies widely.

CONCLUSION

Recent developments in measuring quality of palliative care using quality indicators are mainly quantitative in nature, with a substantial number of new indicators being found. However, the quality of the development process varies considerably between sets. More consistent and detailed methodological descriptions are needed for the further development of these indicators and improved quality measurement of palliative care.

The Intersection of Long-Term Care and End-of-Life Care

High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.

A new set of quality indicators for palliative care: process and results of the development trajectory

CONTEXT

In some countries (the United States in particular), quality indicators for palliative care have already been developed. However, these quality indicators often cover one specific setting or target group, for example, palliative cancer care or palliative home care.

OBJECTIVES

This article describes the development and initial testing of a set of quality indicators for palliative care, applicable for all settings in which palliative care is being provided for adult patients in The Netherlands.

METHODS AND RESULTS

In the first phase of the project, an inventory was made of existing relevant quality indicators. Most quality indicators focused on the process or outcome of palliative care, and quality indicators for the structure of palliative care were rare. Most of the existing quality indicators fall within the domain of physical care, and very few concern the social and spirituals domains of palliative care. In the second phase, a new draft set of quality indicators was developed. In addition to the previous inventory of existing indicators, interviews with patients, relatives, and caregivers provided input for the development of the draft set. Drafts of the set were tested among experts. In the third phase, the feasibility and usability of a draft set was established in 14 Dutch care organizations providing palliative care.

CONCLUSION

As a result of these phases, a set of quality indicators for palliative care has been developed, consisting of 33 indicators for palliative patient care and 10 indicators for support for relatives before and/or after the patient's death.

Quality indicators for palliative care: a systematic review

Research has demonstrated a greater understanding of the needs of terminally ill patients and their families, but it also has been found that the palliative care is not optimal. Because of a lack of quality indicators in palliative care, the quality of the care is often not assessed. The aim of this systematic review was to give an overview of published quality indicators for palliative care in all patient groups and settings, to determine whether these quality indicators cover all domains of palliative care, to describe the different types of quality indicators, and to determine the methodological characteristics of the quality indicators. Relevant studies were identified by searching computerized databases up to December 2007. Publications describing the development process or characteristics of quality indicators for palliative care were selected by two reviewers independently. An additional selection criterion was that numerators and denominators were either defined or could be deduced from the descriptions. The data extraction involved the general description and type of the quality indicator, target population, and applicable setting. We identified 650 publications, of which 16 met the inclusion criteria. These publications described eight sets of quality indicators. These sets contained 142 overlapping quality indicators, covering all but one domain (cultural aspects) of palliative care. Most quality indicators referred to the outcomes or processes of palliative care. The methodological characteristics of the quality indicators varied considerably. We conclude that a substantial number of quality indicators for palliative care are available, but most have not been described in detail. More detailed methodological specifications are needed to accurately monitor the quality of palliative care.

Symptom Experience of Dying Long-Term Care Residents

OBJECTIVES

To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents.

DESIGN

After-death interviews.

SETTING

Stratified random sample of 230 long-term care facilities in four states.

PARTICIPANTS

Staff (n=674) and family (n=446) caregivers for dying residents.

MEASUREMENTS

Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment.

RESULTS

Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=-0.043-0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care.

CONCLUSION

In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life.

Use of the quality improvement process in assessing end-of-life care in the nursing home

OBJECTIVE

To report on the process and effect of a quality improvement project on end-of-life (EOL) care in a state veterans' home.

DESIGN

The design uses survey data from representatives of the deceased, continuous quality improvement (QI) techniques, and interdisciplinary team activities. Representatives of the deceased were surveyed using a tool that assessed symptom management, emotional states, hospice use, and satisfaction with the care provided by the home and the hospice. Using the results of the survey, the interdisciplinary EOL care team used continuous QI methods to improve EOL care.

PARTICIPANTS

Representatives of the deceased of the Thomas Fitzgerald State Veterans Home (TFVH) and the interdisciplinary EOL care team of TFVH, which included staff of TFVH and the hospices serving TFVH.

MEASUREMENTS

The compiled survey results were compared from year to year to assess trends in the following areas: overall quality of care, pain, dyspnea, other uncomfortable symptoms, emotional need, and spiritual needs. We also assessed the degree of depression, agitation and anxiety, loneliness, and preparation and preparedness of the member for death. We surveyed for ratings on the satisfaction with staff, clergy and hospice, clarity of explanations and information provided by TFVH staff, what disciplines provided the emotional and spiritual support for the resident, whether discussions were held about advance directives, if they would recommend TFVH to other families, and use of/satisfaction with the hospice that served their loved one.

RESULTS

The survey return rate was 8 (38%) (2000), 22 (73%) (2001), and 25 (55%) (2002). The specific areas that were improved per the survey results (which also correlated with staff perceptions) were the following: overall quality of care, spiritual care, distribution of work load, and patients' preparedness for death. The prevalence of symptoms was reduced by 22% (pain), 25% (dyspnea), and 30% (uncomfortable symptoms of dying). A marked improvement of involvement of clergy in the spiritual care was also noted. The survey process also identified areas that did not improve or worsened such as management of depression, agitation, anxiety, loneliness, family education, and discussions. During the 2000-2002 time period, an average of 83% of the representatives responded that they would recommend the TFVH to another family.

CONCLUSION

EOL care in nursing homes is rated lower than care in all other venues and must be improved. EOL care can be improved using patient representative surveys as the springboard for staff and hospice interdisciplinary team QI processes. The interdisciplinary team must include the care staff of the home along with hospices serving the institution. We present here one process that we have found effective in improving EOL care. The critical issue is the dedication of the institution and staff to improve EOL care rather than the manner in which it is accomplished.

Physician Communication with Family Caregivers of Long-Term Care Residents at the End of Life

OBJECTIVES

To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions.

DESIGN

Retrospective study of family caregivers of persons who died in LTC.

SETTING

Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities.

PARTICIPANTS

One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death.

MEASUREMENTS

Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96).

RESULTS

Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities.

CONCLUSION

Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

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.

Methodological challenges in measuring quality care at the end of life in the long-term care environment

Understanding what constitutes quality end-of-life care from the perspective of the patient, their family, and health care professionals has been a priority for many researchers in the past few decades. Literature in this area has helped describe many of the barriers to measuring the quality of care in various environments, such as the hospital, hospice, and home. However, much of the work to date in defining the domains of quality care at the end of life has not been conducted within the long-term care environment. This environment is expected to provide care to an increasing number of dying persons with the concurrent aging of the population in many Western countries and demand for more formal services. In this review, the methodological issues involved in measuring quality care at the end of life are examined, with specific attention given to the challenges encountered in the long-term care environment.

Use of the quality improvement process in assessing end-of-life care in the nursing home

OBJECTIVE

To report on the process and effect of a quality improvement project on end-of-life (EOL) care in a state veterans' home.

DESIGN

The design uses survey data from representatives of the deceased, continuous quality improvement (QI) techniques, and interdisciplinary team activities. Representatives of the deceased were surveyed using a tool that assessed symptom management, emotional states, hospice use, and satisfaction with the care provided by the home and the hospice. Using the results of the survey, the interdisciplinary EOL care team used continuous QI methods to improve EOL care.

PARTICIPANTS

Representatives of the deceased of the Thomas Fitzgerald State Veterans Home (TFVH) and the interdisciplinary EOL care team of TFVH, which included staff of TFVH and the hospices serving TFVH.

MEASUREMENTS

The compiled survey results were compared from year to year to assess trends in the following areas: overall quality of care, pain, dyspnea, other uncomfortable symptoms, emotional need, and spiritual needs. We also assessed the degree of depression, agitation and anxiety, loneliness, and preparation and preparedness of the member for death. We surveyed for ratings on the satisfaction with staff, clergy and hospice, clarity of explanations and information provided by TFVH staff, what disciplines provided the emotional and spiritual support for the resident, whether discussions were held about advance directives, if they would recommend TFVH to other families, and use of/satisfaction with the hospice that served their loved one.

RESULTS

The survey return rate was 8 (38%) (2000), 22 (73%) (2001), and 25 (55%) (2002). The specific areas that were improved per the survey results (which also correlated with staff perceptions) were the following: overall quality of care, spiritual care, distribution of work load, and patients' preparedness for death. The prevalence of symptoms was reduced by 22% (pain), 25% (dyspnea), and 30% (uncomfortable symptoms of dying). A marked improvement of involvement of clergy in the spiritual care was also noted. The survey process also identified areas that did not improve or worsened such as management of depression, agitation, anxiety, loneliness, family education, and discussions. During the 2000-2002 time period, an average of 83% of the representatives responded that they would recommend the TFVH to another family.

CONCLUSION

EOL care in nursing homes is rated lower than care in all other venues and must be improved. EOL care can be improved using patient representative surveys as the springboard for staff and hospice interdisciplinary team QI processes. The interdisciplinary team must include the care staff of the home along with hospices serving the institution. We present here one process that we have found effective in improving EOL care. The critical issue is the dedication of the institution and staff to improve EOL care rather than the manner in which it is accomplished.

Hospice Care in Nursing Homes: Does It Contribute to Higher Quality Pain Management?

PURPOSE

The purpose of this study was to investigate pain management among 42 hospice and 65 non-hospice residents in two proprietary nursing homes.

DESIGN AND METHODS

In this prospective, anthropological, quantitative, and qualitative study, we used participant observation, event analysis, and chart review to obtain data. The Medication Quantification Scale was used in order to account for the prescription and administration of all analgesic medications.

RESULTS

Although 72% of residents experienced pain, we found no statistically significant differences in the proportion of hospice versus non-hospice residents (a) who had been prescribed opioids and co-analgesics, and (b) whose medication was administered around the clock or as needed. Limited physician availability, lack of pharmacologic knowledge, and limitations of nursing staff hindered pain management of both groups of residents.

IMPLICATIONS

Although hospice care is of some benefit, pain management and high-quality end-of-life care is dependent upon the context in which it is provided. Given that between 1991 and 2001 Medicare expenditures for nursing home-based hospice care increased from dollar 8.6 million to dollar 21.8 million, the effectiveness of hospice-care programs in nursing homes warrants further study.

Predicting death in the nursing home: development and validation of the 6-month Minimum Data Set mortality risk index

BACKGROUND

Currently, 24% of all deaths nationally occur in nursing homes making this an important focus of care. However, many residents are not identified as dying and thus do not receive appropriate care in the last weeks and months of life. The aim of our study was to develop and validate a predictive model of 6-month mortality risk using functional, emotional, cognitive, and disease variables found in the Minimum Data Set.

METHODS

This retrospective cohort study developed and validated a clinical prediction model using stepwise logistic regression analysis. Our study sample included all Missouri long-term-care residents (43,510) who had a full Minimum Data Set assessment transmitted to the Federal database in calendar year 1999. Death was confirmed by death certificate data.

RESULTS

The validated predictive model with a c-statistic of.75 included the following predictors: a) demographics (age and male sex); b) diseases (cancer, congestive heart failure, renal failure, and dementia/Alzheimer's disease); c) clinical signs and symptoms (shortness of breath, deteriorating condition, weight loss, poor appetite, dehydration, increasing number of activities of daily living requiring assistance, and poor score on the cognitive performance scale); and d) adverse events (recent admission to the nursing home). A simple point system derived from the regression equation can be totaled to aid in predicting mortality.

CONCLUSIONS

A reasonably accurate, validated model has been produced, with clinical application through a scored point system, to assist clinicians, residents, and family members in defining good goals of care around end-of-life care.

Care planning for pressure ulcers in hospice: The team effect

Objective: The standards of care for patients at risk for or with a pressure ulcer in hospitals and nursing homes focus on prevention and ulcer healing using an interdisciplinary approach. Although not a primary hospice condition, pressure ulcers are not uncommon in dying patients. Their management in hospices, particularly the involvement of family caregivers, has not been studied. The objective of this study is to identify the factors that influence care planning for the prevention and treatment of pressure ulcers in hospice patients and develop a taxonomy to use for further study.

Methods: A telephone survey was conducted with 18 hospice directors of clinical services and 10 direct-care nurses. Descriptive qualitative data analysis using grounded theory was utilized.

Results: The following three themes were identified: (1) the primary role of the hospice nurse is an educator rather than a wound care provider; (2) hospice providers perceive the barriers and burdens of family caregiver involvement in pressure ulcer care to be bodily location of the pressure ulcer, unpleasant wound characteristics, fear of causing pain, guilt, and having to acknowledge the dying process when a new pressure ulcer develops; and (3) the “team effect” describes the collaboration between family caregivers and the health care providers to establish individualized achievable goals of care ranging from pressure ulcer prevention to acceptance of a pressure ulcer and symptom palliation.

Significance of results: Pressure ulcer care planning is a model of collaborative decision making between family caregivers and hospice providers for a condition that occurs as a secondary condition in hospice. A pressure ulcer places significant burdens on family caregivers distinct from common end-of-life symptoms whose treatment is directed at the patient. Because the goals of pressure ulcer care appear to be individualized for a dying patient and their caregivers, the basis of quality-of-care evaluations should be the process of care rather than the outcome of an incident pressure ulcer.

Long-term-care residents: concerns identified by population and care trends

OBJECTIVE

Despite rising concern over population aging, few descriptions exist of long-term-care (LTC) residents, the people who are normally the oldest and the most dependent persons. This study sought to describe a LTC resident population and trends in this population.

METHODS

A descriptive-comparative quantitative analysis of all data (1988-1999) from a provincial (Alberta) LTC resident database was undertaken.

FINDINGS

Over the 10-year period, there was a significant increase in care needs. In the 1988, the mean Requirement Score was a "C" (indicating low to medium level care was required); by the 1999, the mean score was "E" (medium to high level care). There were both a substantial reduction in residents with low care needs and an increase in residents with high care needs. Although the mean age of LTC residents increased from 80.5 to 82.5, residents under age 65 had higher care needs. General linear modelling also revealed younger age was a significant influence in regard to higher care needs, along with larger (versus smaller) LTC admission to death also declined significantly from 6.9 to 3.4 years. Although this study may only confirm what is suspected about LTC residents, it should raise discussion over the impact of limited LTC beds on families, community-based health services, and acute care hospitals; and the implications of more dependent residents on LTC facility and personnel planning [corrected]

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.

End-of-life challenges: honoring autonomy

Patients' end-of-life decisions challenge nurses to improve palliative care, symptom management, and patient advocacy, and examine ethical issues. When terminally ill patients take charge of the last stages of life, they may challenge nurses to reexamine attitudes about lifesaving technology and autonomy and values about preserving life. Staff members can become benevolent and believe that they know what is best despite the patient's independent decisions. When patients unsuccessfully decline continued aggressive, life prolonging strategies, they may decide to hasten dying rather than accept a natural death. Researchers (Breitbart WS et al. JAMA. 2000;284:2907-2911) defined desire for hastened death as a unifying construct underlying requests for assisted suicide, euthanasia, and withdrawal of food and fluids. When a terminally ill patient considers a hastened death, the nurse needs to examine the patient's mental health, symptom management, advance directives, and decision making. Medical and psychological symptoms and spiritual distress often trigger thoughts of hastening death even when pain and symptoms have been treated (Breitbart WS et al. JAMA. 2000;284:2907-2911). Ethical issues and guidelines for management of patients and evaluation of rationality are presented.

End-of-life care in nursing homes: residents in hospice compared to other end-stage residents

OBJECTIVE

To compare residents in hospice care at admission to the nursing facility to end stage residents not in hospice at admission.

DESIGN AND METHODS

We analyzed 18,211 admission assessments recorded in the Minimum Data Set (MDS) during the year 2000 throughout the United States for residents classified as having an end-stage disease (6 or fewer months to live). Fifty-nine percent (n = 10,656) of these residents were in hospice care at the time of their admission assessment. We used these MDS admission assessments to compare residents in hospice care to other end-stage residents not in hospice for demographic characteristics, health status, and treatments.

RESULTS

Hospice residents at admission were significantly more likely to be female, older, white, and widowed than other end-stage residents at admission. There were significant differences between hospice residents and other residents at end stage in the use of advanced directives at admission. Hospice residents at admission experienced significantly more frequent and more intense pain than other end-stage residents at admission, while these hospice residents also showed greater impairment in cognitive ability and physical function. While cancer was the most common disease among these end-stage residents, it was significantly more prevalent among hospice residents.

IMPLICATIONS

Many end-stage residents may not be receiving adequate palliative care in nursing facilities; further study of this is warranted. The MDS should be revised to record minimum standards for palliative care with or without the use of hospice to improve end-of life care in nursing facilities.

Integrating case management and palliative care

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.

Lower respiratory infections in nursing home residents with dementia: a tale of two countries

PURPOSE

A focus on palliative care for residents with dementia is much more common in Dutch nursing homes than in the United States. We compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infections (LRI), which are often the immediate cause of death in dementia.

DESIGN AND METHODS

We studied two prospective cohorts--a study of pneumonia (n = 706) conducted in 61 psychogeriatric nursing homes throughout the Netherlands and 701 subjects with likely dementia from a study of LRIs in 36 nursing homes in Missouri.

RESULTS

Nursing home residents with dementia were more often treated without antibiotics in the Netherlands (23%) than in Missouri (15%). Indicators of severe illness operate in opposite directions: more severe illness is associated with antibiotic treatment in the United States, but with palliative treatment without antibiotics in the Netherlands.

IMPLICATIONS

Our findings are consistent with others in indicating problems with transition to palliative care for U.S. nursing home residents with dementia.

Nursing home physician educational intervention improves end-of-life outcomes

CONTEXT

Nursing homes are the setting for one of five deaths in the United States. Unfortunately these deaths are often accompanied by pain and symptoms of discomfort.

OBJECTIVE

To determine if an educational intervention designed for nursing home physicians improves the quality of dying for nursing home residents.

DESIGN

Prospective measurement of changes in end-of-life medical care indicators.

INTERVENTION

Half-day adult educational outreach program, including audit and feedback, targeted at opinion leaders, and quality improvement suggestions.

SETTING

Five geographically diverse Maryland skilled nursing facilities with a total of 654 beds.

PARTICIPANTS

The terminal care delivered by 61 physicians who cared for 203 dying residents in the 5 facilities was reviewed. An intervention was targeted to medical directors and those physicians with the majority of patients. Twelve physicians participated in the educational program.

MAIN OUTCOME MEASURES

Chart documentation of recognition of possible death, presence of advance directives, pain control, analgesics used, dyspnea control, control of uncomfortable symptoms during the dying process, documented hygiene, documented bereavement support, and total patient comfort.

RESULTS

The four nursing facilities that completed the intervention all had significant improvements in end-of-life care outcomes (p < 0.001, chi2). No statistically significant changes were found in any measure in the cohort nursing facility that did not complete the intervention. When we compared residents with hospice services to those without, we found significant increases in documentation of better hygiene, bereavement support, and total patient comfort (p < 0.001, chi2 for each).

CONCLUSIONS

Important terminal care outcomes can be significantly improved by targeting key nursing home physicians with an adult educational program that includes audit and feedback, and quality improvement suggestions.

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

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.

Analyses of nursing home residents in hospice care using the minimum data set

OBJECTIVE

To present comprehensive profiles of residents in hospice care at admission to the nursing home using the Minimum Data Set (MDS).

DESIGN AND SETTING

We analysed 40,622 MDS admission assessments for nursing home residents in hospice care. The MDS contains resident-focused data on pain, cognitive patterns, physical function, disease diagnoses, medications, nutrition, and specific treatments received.

RESULTS

About four in five recently admitted hospice residents had 'do not resuscitate' orders and only 27% had a living will. Over 70% of recently admitted hospice residents experienced pain, with almost one half experiencing daily pain. Over one half of those hospice residents in pain experienced moderate pain and almost one third experienced horrible or excruciating pain. About 57% of recently admitted hospice patients had cancer, 21 % had congestive heart failure, 20% had emphysema/chronic obstructive pulmonary disease, and 18% had depression. About one in two recently admitted hospice residents exhibited at least moderate impairment in cognitive function.

CONCLUSIONS

There is a need to improve pain management, advanced directives, and mental health services for residents dying in nursing homes.

The role of hospice care in the nursing home setting

The last days of life for a substantial proportion of dying older adults are spent in nursing homes. Considering this, the provision of Medicare hospice care in nursing homes would appear to be an equitable use of Medicare expenditures as well as a valid investment in improving the quality of life for dying nursing home residents. However, government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting. Currently, access to hospice care in nursing homes is inequitable across facilities, and across geographic areas. In nursing homes where hospice is available and present, however, recent research documents superior outcomes for residents enrolled in hospice, and perhaps for nonhospice residents. Still, more research is needed, particularly research focusing on the government costs associated with the provision of hospice care in nursing homes. If subsequent research continues to support the "added value" of hospice care in nursing homes and at the same or less total costs, the issue of foremost concern becomes how equitable access to Medicare hospice care in nursing homes can be achieved. Access may be increased to some extent by changing government policies, and conflicting regulations and interpretive guidelines, so they support and encourage the nursing home/hospice collaboration.

As individual as death itself: a focus group study of terminal care in nursing homes

One in four Americans who reach the age of 65 will die in a nursing home, yet little research exists to define the end of life care needs of this population. We used focus groups with experienced nursing home staff and physicians to: (1) define a good death in a nursing home and (2) describe factors that promote or prevent good care for the dying in this setting. We audiotaped 11 focus groups with 77 participants. Discussions were structured around 3 questions: "How does someone die in the nursing home?" "What makes the difference between a good death and a bad death?," and "What can aides, nurses, or physicians do to help ensure that when someone dies it is a good death?" Participants described lack of training, regulatory emphasis on rehabilitation, and a resource-poor setting as important barriers to high quality care of the dying in nursing homes. They affirmed the value of their experience and personal relationships with residents as the basis for good care. Three major themes emerged to define a good death in a nursing home: highly individualized care based on continuity relationships with caregivers, effective teamwork by staff, physicians and family, and comprehensive advance care planning that addresses prognosis, emotional preparation, and appropriate use of medical treatments. The significance of these themes may be tested in the design of interventions to improve care of the dying in long-term care.

This is Heaven's waiting room: end of life in one nursing home

The purpose of this study was to describe the end of life in one midwestern nursing home from the perspective of residents who are chronically ill and declining, their family caregivers, and staff. Qualitative methods, including formal and informal interviews, participant observation, and health record abstraction, were used to describe the end of life for 13 nursing home residents. One dominating pattern, conflict, and five themes (i.e., communication, quality of life, staff education, teamwork, work environment) emerged as factors that influenced end-of-life care. The results of this study illustrate where and how problems within the nursing home industry, the participating nursing home, and between staff and residents influence and challenge care provided to dying residents.

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES

To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community.

DESIGN

Retrospective review of computerized clinical care records.

SETTING

A metropolitan nonprofit hospice.

PARTICIPANTS

The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community.

MEASUREMENTS

Patient characteristics, needs for palliative care, and survival.

RESULTS

At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups).

CONCLUSIONS

These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.

Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members

A fundamental barrier to improving the quality of medical care at the end of life is the lack of measurement tools. The Toolkit of Instruments to Measure End of Life Care (TIME) aims to fill that void by creating measurement tools that capture the patient and family perspective. To develop a conceptual model for a retrospective survey of bereaved family members that incorporates both professional and family perspectives on what constitutes good care at the end of life, a qualitative literature review of existing professional guidelines and six focus groups with bereaved family members from acute care hospitals (n = 2), nursing homes (n = 2), and hospice/VNA home health services (n = 2) was performed. The focus groups were held in Arizona, New York, and Massachusetts and included 42 bereaved family members/friends contacted 3-12 months from the time of patient's death. Domains of care that define quality end-of-life care were defined. Focus group participants defined high quality medical care as: 1) providing dying persons with desired physical comfort; 2) helping dying persons control decisions about medical care and daily routines; 3) relieving family members of the burden of being present at all times to advocate for their loved one; 4) educating family members so they felt confident to care for their loved ones at home; and 5) providing family members with emotional support both before and after the patient's death. The qualitative literature review yielded similar results, except that the professional guidelines did not mention the advocacy burden felt by families. These two sources provided the foundation for a conceptual model of patient-focused, family-centered medical care and a new tool for surveying bereaved family members. Views of bereaved family members' stories and professional guidelines help to identify key domains of quality of end-of-life care. A new survey instrument provides a way to incorporate the perspectives of bereaved family members in measuring the quality of end-of-life care.

Pain in the nursing home

The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.

Death and dying: management of patients with end-stage disease

The culture of nursing homes historically has been rehabilitative. This approach has been enforced by the Omnibus Budget Reconciliation Act (1987) regulations, which focus on "decline" as largely avoidable. With the passage of the Prospective Payment System, nursing homes have become increasingly a site of death. In the same way that no sharp transition exists between living and dying, no sharp transition exists between life-prolonging, disease-specific therapy and palliative therapy. Life-prolonging therapy can lead to symptoms that require palliation, and, in some instances, (e.g., end-stage heart failure) life-prolonging therapy and palliative therapy may be indistinguishable. Palliative care, with the control of symptoms, relief of suffering, and promotion of quality of life, is appropriate to all stages of disease, with an increasing proportion of palliative care relative to curative therapy as the disease progresses. The goals of symptom management and attention to potential sources of suffering in palliative care are components of quality end-of-life care and are discussed.

Care of the dying in long-term care settings

A team of caregivers provides health care in nursing homes. This team is led by a nurse and includes a physician, nursing assistants, and other nursing home staff. Given the future demand for palliative care in this setting, the roles of all caregivers need to be supported with meaningful training, improved working conditions, and respect for each caregiver's contribution.

The case for hospice care in long-term care environments

Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care of conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

The Medicare Hospice Benefit's Influence on Dying in Nursing Homes

For dying nursing home residents, the prevalence of symptoms and care utilization prior to death has yet to be empirically described for a population-based sample. Yet, related work has suggested that the quality of care for dying nursing home residents is less optimal. The provision of Medicare hospice care in nursing homes offers a means for improving terminal care in nursing homes. However, other than controversial findings emanating from the U.S. Office of Inspector General's (OIG's) hospice studies, there is a dearth of evaluative research on the comparative costs and the benefits of Medicare hospice care in nursing homes. In this article, we discuss current knowledge concerning the dying experience of nursing home residents and of the influence of the Medicare hospice benefit in nursing homes. In doing so, we critique the OIG's study of hospice care in nursing homes and we raise concerns regarding access to the Medicare hospice benefit in nursing homes. We conclude by delineating the research needed to more fully understand the dying experience of nursing home residents and the influence of Medicare hospice care provision on this experience.

The experience of living-dying in a nursing home: self-reports of black and white older adults

PURPOSE

The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living-dying interval. The living-dying interval is defined as the time between the knowledge of one's impending death and death itself.

DESIGN

This qualitative study was part of a larger ethnographic project. Residents participated in from one to four individual, in-depth, semi-structured, audiotaped interviews.

SETTING

Residents lived in two large county-financed nursing homes that have historically provided care to indigent black and white older adults.

PARTICIPANTS

Purposive sampling was used to identify eight black and five white residents with terminal cancer diagnoses who could serve as rich resources about the experience of living-dying in a nursing home.

MEASURES

Residents were asked open-ended questions about how things have been and what would make things better; what comforts them and would make them more comfortable; what dying means to them; and what things are important for nursing staff to know.

RESULTS

Verbatim transcripts of the interviews were coded using QRS NUD-IST software. Codes were placed in categories, categories were reviewed for common and different concepts, themes, and patterns, and a conceptual model was developed. The model identified six care needs: (1) day-to-day living; (2) inadequate pain relief for black residents; (3) difficulty chewing and swallowing; (4) importance of religious activities; (5) giving care to others; and (6) appreciation of respectful and prompt care. Residents validated all components of the conceptual model.

CONCLUSION

Black and white terminally ill residents focused on the quality of living rather than on dying, and black residents may be undertreated for pain. Important care needs for pain and religion are not routinely addressed by the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) triggers.

Assessing medical care of dying residents in nursing homes

Although approximately one of five people in the United States die in nursing homes (NHs), little has been written about their quality of dying, including the quality of terminal medical care. The purpose of this study is to review actual medical practices in NHs to suggest factors important for delivering good quality terminal care. Four NHs were surveyed for management of residents who died in 1992. A convenience sample of charts of newly admitted and longer term residents were abstracted for demographic variables, death, diagnostic categories, and various laboratory and other parameters. Charts of those residents who died were further reviewed using indicators of quality medical care, such as presence of advance directives, control of pain, and control of dyspnea, based upon recent published clinical practice guidelines for terminal care in NHs. Three hundred and seventy-one charts were abstracted. Forty-one charts documented the resident's death. We found that NHs without regulatory difficulties usually had expected deaths that were managed approximately as measured by terminal medical care quality indicators. NHs with a history of regulatory difficulties had a higher prevalence of residents who died suddenly and unexpectedly, often with problems in the quality of care as measured by the same indicators. There was a correspondence between physician certification, antemortem diagnosis of terminal illness, and appropriate terminal care. We conclude that physicians are able to recognize impending death and redirect the medical care of dying NH residents toward goals of terminal care management. This is more likely to occur in a NH environment that places greater emphasis upon total quality management. We suggest that another indicator in providing good NH terminal care is the physician's performance in predicting a short life expectancy.

Quality indicators in clinical nursing: a review of the literature

The purpose of the present study was, by means of a literature review, to describe and analyse the characteristics of clinical indicators used to assess and promote quality improvement in nursing care. It was found that a generally accepted definition of a clinical indicator is a 'quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care and support service activities'. By the seriousness of the event and the degree to which it can be avoided, clinical indicators are described as sentinel event or rate-based indicators. They can measure structure, process or outcome of care. Authors have had different approaches in focus when selecting and developing indicators viz. specific aspects of care/nursing diagnosis, medical diagnosis, generic aspects of care and clinical areas. These different points of departure were influenced by research knowledge, theories/frameworks, or by the opinions of patients or staff. The threshold of an indicator is essential when measuring the quality of care as it describes a critical level between what is considered good or not. Thresholds should be dynamic, realistic, and improve over time. However, the literature on how to establish specific thresholds is limited. The review has also revealed that there is an uncertainty regarding the use of terms such as indicators, standards, norm, criteria and aspects of care.