Access to Palliative Care and Hospice in Nursing Homes

Abstract

Nursing homes are the site of death for many elderly patients with incurable chronic illness, yet dying nursing home residents have limited access to palliative care and hospice. The probability that a nursing home will be the site of death increased from 18.7% in 1986 to 20.0% by 1993. Dying residents experience high rates of untreated pain and other symptoms. They and their family members are isolated from social and spiritual support. Hospice improves end-of-life care for dying nursing home residents by improving pain control, reducing hospitalization, and reducing use of tube feeding, but it is rarely used. For example, in 1997 only 13% of hospice enrollees were in nursing homes while 87% were in private homes, and 70% of nursing homes had no hospice patients. Hospice use varies by region, and rates of use are associated with nursing home administrators' attitudes toward hospice and contractual obligations. Current health policy discourages use of palliative care and hospice for dying nursing home residents. Quality standards and reimbursement rules provide incentives for restorative care and technologically intensive treatments rather than labor-intensive palliative care. Reimbursement incentives, contractual requirements, and concerns about health care fraud also limit its use. Changes in health policy, quality standards, and reimbursement incentives are essential to improve access to palliative care and hospice for dying nursing home residents. JAMA. 2000;284:2489-2494.

Perceptions of Coordination of Care Between Hospice and Skilled Nursing Facility Care Providers

“…Once admitted, the majority of residents' length of stay is less than six months 25 . The provision of hospice care in the Skilled Nursing Facility provides benefits such as reduced hospitalizations, better assessment and management of pain as well as family and spiritual support for dying residents 4,11,15,17,18,22,24,26 . This study supports the need for collaboration for quality end-of-life care.…”

“…In addition, many residents become like family members to NH/SNF staff and the initiation of hospice care may cause territorial issues due to their ownership of the resident's care. Also, it may indicate the NH/SNF staff feels that this care is already being delivered in their environment and hospice is seen as a duplication of their services while NH/SNF staff must continue to provide an acceptable level of personal care unrelated to terminal care 22 . These differences in care goals may present continued challenges to the NH/SNF staff.…”

Palliative care in nursing homes: a comparison of high- and low-level providers

“…Broader acceptance of palliative care requires a shift in the culture of long-term care (Kristjanson et al, 2005). Advocates have identified a number of cultural barriers to providing adequate end-of-life care in nursing facilities, including inadequate support of staff caring for dying residents, the emphasis of regulations on restorative care (Ersek and Wilson, 2003;Froggatt et al, 2002) and a reluctance to collaborate with outside hospice providers (Zerzan et al, 2000). In addition, previous ethnographic and mixed-methods research has found that nursing facilities that incorporate the idea of caring for the dying individual into daily care processes and policies provide optimal palliative care (Travis et al, 2002;Forbes-Thompson and Gessert, 2005;Currow and Hogarty, 2006).…”

A New Medicare End-Of-Life Benefit For Nursing Home Residents

“…18 In fact, several of these measures can be natural symptoms in the dying process, including functional decline, weight loss, reduced respiration, and dehydration. Given the use of the MDS measures in regulatory oversight and public reporting, nursing facility administrators express concern that these natural developments among dying residents are misinterpreted as poor quality of care.…”

“…17,18 Providing supplemental payments to nursing homes for end-of-life services and holding facilities accountable for the quality of end-of-life care should help resolve some but not all of these barriers. Nursing homes located in areas not served by a hospice will have no choice but to provide the services themselves and address these remaining barriers.…”