Potentially burdensome end‐of‐life transitions among nursing home residents with poor‐prognosis cancer

Abstract

Background This study examined factors associated with potentially burdensome end‐of‐life (EOL) transitions between care settings among older adults with advanced cancer in nursing homes (NHs). Methods A retrospective analysis of deceased older NH residents with poor‐prognosis solid tumors was conducted with Medicare claims and the Minimum Data Set. A potentially burdensome transition was defined as 2 or more hospitalizations or an intensive care unit admission in the last 90 days of life. Results Among 34,670 subjects, many had moderate to severe cognitive impairment (53.8%), full dependence in activities of daily living (ADLs; 66.5%), and comorbidities such as congestive heart failure (CHF; 29.3%) and chronic obstructive pulmonary disease (34.1%). Only 56.3% of the patients used hospice at any time in the 90 days before death; 36.0% of the patients experienced a potentially burdensome EOL transition, and this was higher among patients who did not receive hospice (45.4% vs 28.7%; P < .01). In multivariable analyses, full dependence in ADLs (odds ratio [OR], 1.70; P < .01), CHF (OR, 1.48; P < .01), and chronic obstructive pulmonary disease (OR, 1.28; P < .01) were associated with a higher risk of burdensome EOL transitions. Those with do‐not‐resuscitate directives (OR, 0.60; P < .01) and impaired cognition (OR, 0.89; P < .01) had lower odds of burdensome EOL transitions. Conclusions NH residents with advanced cancer have substantial comorbidities and functional impairment, yet more than a third experience potentially burdensome EOL transitions. These findings help to identify a population at risk for poor EOL outcomes in order to target interventions, and they point to the importance of advanced care planning in this population.

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

“…Next, the remaining 37 articles underwent full-text review, which resulted in 17 studies that were deemed eligible for inclusion. An additional article 27 was identified through an ascendency and descendancy search for a final total of 18 included articles. Supplementary Figure 1 lists exclusion reasons during full-text review.…”

“…38 Of those that did report on the residents' serious illness, all reported on the concentrations of NH residents with Alzheimer disease and Alzheimer-related dementias (AD/ADRDs), followed by residents with cancer (n ¼ 11; 61.1%), 27e31,33,34,36,41,43 residents with heart disease (n ¼ 6; 33.3%), 27,31,34,36,41,43 residents who were stroke survivors (n ¼ 5; 27.8%), 28,31,34,41,43 and residents with chronic obstructive pulmonary disease (n ¼ 5; 27.8%). 27,28,33,36,43 The proportion of White NH residents ranged from 67% 35 to 91%. 31 Black NH residents were represented in 14 studies 28e33,35e37,40e44 and proportions ranged from 2.5% 41 to 29%.…”

Cultural and Ethical Barriers to Cancer Treatment in Nursing Homes and Educational Strategies: A Scoping Review

“…This category includes seven studies distributed in three subcategories: deprescription, difficulties related to transition between long-term care and hospitals, and quality indicators [ 67 , 68 , 69 , 70 , 71 , 72 , 73 ].…”

“…Associated factors were full dependence on ADLs, congestive heart failure, and chronic obstructive pulmonary disease. Those with impaired cognition and do-not-resuscitate orders had the lowest risk of transfer [ 70 ]. A study explored frontline nurses’ perspectives on the transition of cancer patients with care needs from a gastroenterology ward.…”

“…When approaching the end of life, caring for a dying patient is known to be challenging [ 64 , 65 , 66 ]. Comfort care and deprescription as standards of care in nursing homes are sometimes in conflict with the continuum of cancer care that has the potential to vary in therapeutic intensity and medical instability over time [ 67 , 68 , 69 , 70 ]. Incapacity to achieve comfort and manage medical instability in this setting may lead to acute care transfer and, therefore, care discontinuation because of bidirectional communication difficulties [ 69 , 88 ].…”