Palliative care opportunities in the LTC setting

As care institutions, both hospices and nursing homes have the opportunity to create family-friendly programs and policies that make the difficult end-of-life period a time of closeness and bonding. By removing the burdens of care and creating a supportive environment, we can liberate the family to concentrate on their relationships, resolving their issues, and saying the all too important "thank you," "I love you, " "I forgive you," and "good-bye."

Beyond family-friendly policies, how can we change community perceptions of nursing homes as less than desirable alternatives? Given reimbursement constraints, the strict regulation of long-term care facilities, and high staff turnover, institutional change is challenging. During the past few years, however, many very practical programs have been developed as nursing homes seek affordable ways to integrate palliative care into their daily workflow. For instance, St. Joseph's Manor in Connecticut was able to increase family satisfaction and help staff cope with loss by sending sympathy cards to the survivors and making a memory box in honor of the patient.

As noted above, long-term care facilities that have hospice contracts are recommended as the first choice for physician referral. Studies indicate that residents on hospice care are more likely to have their pain assessed and managed and are less likely to have physical restraints or receive inappropriate medications (Miller and colleagues, 2002; Miller and colleagues, 2003). Moreover, in a comparison study, families rated nursing home care with hospice participation higher than nursing home care alone (Baer & Hanson, 2000).

To identify residents whose symptoms and goals of care made them appropriate candidates, a JAMA article (Casarett and colleagues, 2005) described the results of a randomized clinical trial of criteria gathered from a brief interview composed of roughly 20 simple questions concerning symptoms and preferences regarding life support (e.g., CPR, and the use of a mechanical ventilator). If the interview indicated preferences that made a hospice referral appropriate (i.e., emphasis on palliative and quality of life), the resident's physician was sent a fax to this effect. The study team found that 20% of the treatment residents eligible for hospice signed on for hospice care within 30 days of the interview, whereas only 2% of the hospice-eligible control residents ended up receiving hospice services. The treatment group had fewer acute care admissions and spent fewer days in an acute care setting. In addition, family ratings of care in the treatment group were higher than those in the control group.

There are many ways that hospice and long term care facilities can partner to improve the end-of-life experience. Please give us a call at (843) 347-5500. We'd love to explore the options with you.

Hospice and long-term care partnerships in South Carolina

According to 2004 statewide data available through the Carolinas Center for Hospice and End-of-Life Care, 86 nursing home residents in Horry County received hospice service for a total of 7,032 days of care. This represented only 2.84% of total nursing home bed utilization. With their frail status and high levels of pain, residents of long-term care facilities are prime candidates for hospice care.

Long-term care facilities and hospice make a logical partnership. Mercy Hospice and Palliative Care, for instance, can provide inservice training for your staff and attend your IDT meetings to assist with care planning.

Even those residents who choose not to forego curative treatment can receive outpatient palliative care services to ease their pain and discomfort. Palliative care is not yet reimbursable by Medicare. However, through grant funding and generous donations, Mercy Hospice and Palliative Care can provide this service in long-term care facilities regardless of the resident's ability to pay.

Persons receiving palliative care are evaluated by an interdisciplinary team that includes a nurse practitioner, a chaplain and a social worker. They provide consultative services to your facility, however your medical director remains the attending physician.

If you would like to refer a resident for hospice or palliative care services, please feel free to use our secure and confidential online referral request form, or give Mercy a call at 843-347-5500.

Training resources

Pain management

As the institution dedicated to the most frail, it is no wonder that nursing homes have a very high percentage of residents in pain. Appropriate pain management is an ongoing challenge. For those residents who are hospice eligible, research shows that they are more likely to have their pain assessed and managed if they are concurrently on hospice care (Miler and colleagues, 2002). That said, there is much that long term care facilities can do to ease the pain of residents. Those interested in focusing on this aspect of care might be interested in reading the work of Hutt and colleagues (2006). They piloted a nursing home Pain Medication Appropriateness Scale with 2000 Colorado nursing home residents and found it to be a promising quality improvement tool.

Other pain management resources are available below:

Quality improvement

Advance directives

Despite high-profile cases such as that of Terry Schiavo, the majority of Americans have yet to complete an advance directive. Our website can help. The Important Decisions section has an initial article about quality of life that is designed to prompt thinking about what makes life worth living and what might, for each individual, be considered "worse than death." The article about health care planning describes the elements of an advance directive. It then provides specific information about the most commonly used forms of life support. At the end of each description is a quote from an individual that serves as a springboard for discussion: Does the viewer agree or disagree with the quote? What would the viewer say instead? Finally, there is an article about starting the conversation that includes tips for getting past the barriers that commonly occur when trying to talk to a family member about their health care planning.

Below is a list of other online resources pertaining to advance directives.

Ethical issues

Due to the frailty of its residents and a volatile press, nursing homes often find themselves publicly in the crosshairs of difficult ethical issues. Nursing home staff are daily called upon to make hard decisions, from pain management, and tube feeding, to requests for assisted suicide. The "rubber meets the road" in your institution, where practical realities vie with cultural attitudes and societal concerns.

As a long term care facility with significant public oversight, you need information to support you in the creation of policies and procedures that guide your employees.  If you are looking for evidence-based approaches to ethical caregiving, you may want to check out the resources listed below.

References

Baer, W. M., & Hanson, L. (2000). Families' perception of the added value of hospice in the nursing home. Journal of the American Geriatric Society, 48, 879-882.

Carolinas Center for Hospice and End of Life Care. (2004). 2004 NC and SC hospice data trends. Retrieved 2/9/07 from the Internet at http://www.carolinasendoflifecare.org/Statistics2004.html.

Casarett, D., Karlawish, J., Morales, K., Crowley, R., Mirsch, T., & Asch, D.A. (2005). Improving the use of hospice services in nursing homes: A randomized clinical trial. JAMA, 294(2), 211-217.

Hanson, L., & Ersek, M. (2006). Meeting palliative care needs in post-acute care settings: To help them live until they die. JAMA, 295(6), 681-686.

Hutt, E., Pepper, G. A., Vojir, C., Fink, R., & Jones, K. R. (2006). Assessing the appropriateness of pain medication prescribing practices in Nursing Homes. Journal of the American Geriatrics Society, 54(6), 231-239.

Miller, S., Mor, V., & Teno, J. (2003). Hospice enrollment and pain assessment and management in nursing homes. Journal of Pain and Symptom Management, 26, 791-799.

Miller, S., Mor, V., Wu, N., Gozalo, P., & Lapane, K. (2002). Does receipt of hospice care in nursing homes improve the management of pain at the end of life? Journal of the American Geriatric Society, 50, 507-515.