Dying in America--an examination of policies that deter adequate end-of-life care in nursing homes

Better Regulation of End-Of-Life Care: A Call For A Holistic Approach

Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying "regulatory space" theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers.

Hospice care in the nursing home setting: a review of the literature

The U.S. Medicare hospice benefit has expanded considerably into the nursing home (NH) setting in recent years. This literature review focuses on the provision of NH hospice, exploring its growth and the impact of such care on NH residents, cost and efficiency implications for NHs and government, and policy challenges and important areas for future research. Although hospice utilization is relatively modest among NH residents, its increased availability holds great promise. As an alternative to traditional NH care, hospice has been shown to provide high-quality end-of-life care and offer benefits, such as reduced hospitalizations and improved pain management. The provision of NH hospice also has been shown to have positive effects on nonhospice residents, suggesting indirect benefits on NH clinical practices. Importantly, the expansion of hospice in NHs brings challenges, on both clinical and policy dimensions. Research has shown that NH-hospice collaborations require effective communication around residents' changing care needs and that a range of barriers can impede the integration of hospice and NH care. Moreover, the changing case mix of hospice patients, including increased hospice use by individuals with conditions such as dementia, presents challenges to Medicare's hospice payment and eligibility policies. To date, there has been little research comparing hospice costs, service intensity, and quality of care across settings, reflecting the fact that few comparative data have been available to researchers. The Centers for Medicare & Medicaid Services have taken steps toward collecting these data, and further research is needed to shed light on what refinements, if any, are necessary for the Medicare hospice program.

Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents

PURPOSE

We investigated the role of race in predicting the likelihood of using hospice and dying in a hosptial among dual-eligible (Medicare and Medicaid) nursing home residents.

DESIGN AND METHODS

This follow-back cohort study examined factors associated with hospice use and in-hospital death among non-Hispanic Black and non-Hispanic White dual-eligible nursing home residents (N = 30,765) who died in Florida during one of three years: 2000, 2001, or 2002. We used logistic regression models to identify independent predictors of hospice use and in-hospital death.

RESULTS

After we controlled for other factors, Black residents were significantly less likely to use hospice and more likely to die in a hospital. Principal cause of death moderated the relationship between race and hospice use: Black residents were significantly less likely to use hospice than White residents among residents without cancer as principal cause of death, but there was no difference among residents with cancer as cause of death. Further analyses for each racial group revealed that the impact of cause of death in predicting hospice use was greater among Black residents than White residents.

IMPLICATIONS

Hospice care offers many benefits, including reduced risk of in-hospital death, but Black nursing home residents are less likely to use hospice and may have different perceptions of need for hospice care compared with White residents. Future research and outreach efforts should focus on developing culturally sensitive, disease-focused end-of-life education and communication interventions that target residents, families, nursing home providers, and physicians.

Characteristics of Patients Receiving Hospice Care at Home Versus in Nursing Homes: Results From the National Home and Hospice Care Survey and the National Nursing Home Survey

This study examined 1170 deceased home hospice patients from the 1998 National Home and Hospice Care Survey and 617 deceased nursing home hospice patients from the 1997 and 1999 National Nursing Home Surveys. T tests and Bonferroni adjustments for multiple comparisons were performed to assess differences in characteristics of patients receiving hospice care at home versus in nursing homes. We found that the nursing home hospice population differs significantly from the home hospice population in the United States. Nursing home hospice patients were more likely to be older, have Medicaid as their primary payment source, have dementia and other noncancer primary diagnosis, and receive dietary/nutrition service, medication management, and physician services than home hospice patients.

End-of-life care: an educational intervention for rural nurses in southeastern USA

AIM

To assess the impact of three educational presentations as an intervention for increasing knowledge of end-of-life care for rural nurses in assisted living and nursing home environments.

DESIGN

A repeated measures design (quantitative component) evaluated the effects of the educational intervention. Two open-ended questions yielded qualitative data.

SAMPLE AND SETTING

A convenience sample (n = 9) of Registered Nurses and Licensed Practical Nurses employed in an assisted living facility or nursing home in the rural, southeastern region of the USA. Level of nursing experience ranged from 6 to 28 years.

ANALYSIS

Frequency distributions, difference of means test for paired samples.

RESULTS

Post test scores were significantly higher (t = 6.999; p < 0.001) than pretest scores regarding overall knowledge on end-of-life care. Attitudes and perceptions of participants changed in defining what constitutes a 'good death'.

CONCLUSIONS

Classroom educational presentations are an effective means of changing attitudes and improving end-of-life care knowledge. Additional education and support for rural nursing personnel involved with residents of long-term care may enhance end-of-life care.