Context Over the past century, nursing homes and hospitals increasingly have become the site of death, yet no national studies have examined the adequacy or quality of end-of-life care in institutional settings compared with deaths at home.

This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.

Sustained efforts on many fronts are needed to improve end-of-life care in nursing homes. Policy recommendations are suggested.

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

Human observers can discriminate a 5% difference in velocity for a wide range of velocities. Using an apparent-motion stimulus, we demonstrated that velocity discrimination depends on the detection of small changes in asynchrony, changes of the order of 1 msec or less. The simplest component of an apparent-motion stimulus is a pair of spatially separate lines presented asynchronously. Generally the incremental asynchrony threshold for a single pair of lines is much too large to account for velocity discrimination. A sequence of five to eight asynchronously presented targets, equivalent to continuous motion viewed for a duration of 80-100 msec is required to reach asymptotic velocity discrimination. Our experiments rule out probability summation as the explanation for the enhanced temporal sensitivity observed with the sequential presentation of multiple asynchronous targets. Sequential recruitment, a descriptive term for this enhanced temporal sensitivity, depends on the summation of a velocity-specific signal within the physiological network responding to motion.

End-of-life advocacy takes on increased urgency when those close to the dying resident have concerns about basic care and do not understand the dying course. Enhancing communication, preparing families at the end of life, and better understanding of hospice are likely to increase family trust in nursing home care, improve the care of dying residents, and help reduce family burden.

No abstract

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.