Last month the "Lunch Bunch" discussed problems in end-of-life care in nursing facilities and ways to overcome barriers to good care. Co-sponsored by the American Association of Homes and Services for the Aging (AAHSA) and ABCD, Timothy Keay, M.D., a faculty scholar from the Project on Death In America, was the keynote speaker.
Some problems may be attributed to rapid changes in the nursing home industry. In 1975, nursing homes had fewer than fifty beds; today they average more than 100 beds. Small, family-owned facilities have given way to much larger, for-profit corporations. Many people who might once have gone to nursing facilities now move to assisted-living facilities, leaving the "sickest of the sick" to nursing homes. There are now more assisted-living than nursing home beds in the United States.
Keay pointed out that 1987 reforms for nursing facilities required them to maintain or improve patient function - since nursing facilities generally do neither for dying patients, Keay suggested that it is "virtually illegal for a patient to die in a nursing facility without hospice care."
Cost is a barrier to providing hospice care in nursing facilities: Hospice in nursing facilities costs approximately $900 for one patient, while home hospice costs $550 for 5 patients. Many nursing facilities have little experience working with hospice, and few have ongoing contracts with hospices. Some nursing facilities avoid hospice contracts because of payment delays.
Dr. Keay described a study he has made of ways to improve palliative care in nursing facilities in Maryland. Keay offers a half-day training program on palliative care for nursing home physicians, taking baseline data before and six months after the program. In one Baltimore facility, the number of "unexpected" deaths went from 30% to less than 5%; at the same time, the percentage of critically ill patients increased from less than 15% to more than 35%. Hospice referrals and advance directives increased, while pain and other symptoms decreased.
Keay said that ultimately, the goal in nursing facilities should be to routinely provide good end-of-life care to all dying residents, rather than transferring patients back and forth from nursing facilities to hospitals. Pain management, symptom control, and bereavement support must be part of care for all patients. Keay recommended identifying and using best practices, training all nursing facility staff, and conducting continuous quality improvement. Facilities need to develop systems for tracking key data about end-of-life care.
Through his experiences, Dr. Keay has found the best practices for end-of-life care to include: one full-time hospice nurse per 100-beds, routine pain assessment, use of interdisciplinary teams, and ongoing quality improvement program for palliative care. In addition, hospice principles can and should be applied to the care of residents dying in nursing homes.
Stephen Connor, Ph.D., research director for the National Hospice Organization briefly reviewed findings from the NHO "Nursing Home Task Force Report," whose recommendations included promoting use of NHO guidelines for hospice in nursing facilities, requiring that patients receive hospice care from an organization that promotes continuity of care across settings, promoting hospice care in assisted-living environments, and addressing problems in the payment structures for hospice care in nursing facilities.
Katie McGoldrick in an intern for Americans for Better Care of the Dying.
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