Palliative Care In The Nursing Home—Shifting Paradigms ✓ Solved

Palliative Care in the Nursing Home—Shifting Paradigms

When asked about their preferred location of death, most people say they would like to die at home. Few people say they would like to die in the hospital. Nobody ever says they want to die in a nursing home (NH). But the reality is that many people will live out their final days and take their last breaths in the NH setting. In 2009, more than 1 in 4 decedents in the United States died in an NH. This number is only expected to grow with population aging. For years, death in the NH has been viewed as a bad outcome resulting from poor-quality care. Since the middle of the 20th century, NHs have been subject to regulatory scrutiny that viewed any sign of resident’s decline as an indicator of NH negligence.

This fact, combined with financial incentives that reward rehabilitative care, has resulted in NHs that are justifiably skittish about acknowledging death and decline in their residents. However, the truth is that most people who enter the NH are in their final months or years of life. Decline and death are expected and inevitable outcomes. Denial of death and dying in the NH makes it impossible to recognize and address the many palliative care (PC) needs of this population. Limited access to high-quality end-of-life (EOL) care means these vulnerable individuals are deprived of services that could ameliorate their symptoms, provide anticipatory guidance, and offer social and emotional support in their final days.

We are beginning to see a paradigm shift in acknowledging serious illness and death in the NH setting. Efforts to improve the quality of EOL care for NH residents are underway. Results from the PACE study reported in the study by Van den Block et al demonstrate how the scope of these efforts is expanding. This ambitious, multinational, cluster-randomized clinical trial aimed to test whether a train-the-trainer PC intervention could improve quality of EOL care for NH residents in 7 European countries. Although this study showed slight improvements in staff knowledge of PC, there was no difference in NH residents’ comfort in the last week of life—the study’s primary outcome.

Although these negative findings are perhaps disappointing to the study investigators and readers, they raise important questions and issues that inform the path forward. Why did the intervention fail to reach its intended outcomes? The short and rather vexing answer is: we do not know. The authors propose several reasons: (1) the intervention was too complex; (2) the intervention implementation was sub-optimal; and (3) the intervention components and primary outcome measure did not align. In another recently published article, the PACE investigators discuss in greater detail challenges they faced in recruiting and collecting data in NHs in England, providing useful clues as to what may have happened internationally.

Three quarters of eligible nursing homes in England did not respond or refused to participate. Managers for NHs who agreed to participate were often not present or forgot about the study at the time the researcher made the prearranged on-site visit. Most importantly, the investigators rightly noted that a single visit by the research team hampered the development of a relationship between the NH and research team. Thus, enthusiasm for the study may have been low to begin with, and was not helped by the scant contact between the research team and study NHs. What these findings underscore is just how critical it is to address, monitor, and document intervention fidelity and implementation processes in clinical trials, especially for multicomponent behavioral interventions intended to address complex multi-faceted constructs, such as EOL care.

Without robust data on implementation processes from other international sites beyond England, we are left wondering what happened. Furthermore, this study highlights how challenging it is to affect patient-centered outcomes in palliative and EOL care research, particularly in the complex environment of the NH. The limited availability of appropriate measurement instruments, recall and proxy bias, and ceiling effects are all methodological challenges to measuring patient-centered outcomes in PC research. Add to this the challenges of conducting research in the NH—including high rates of staff turnover, lack of incentives for engaging in research, remote family members—it is remarkable that even this limited degree of research succeeds in the NH.

The PACE investigators should be commended for undertaking such a large-scale, thoughtfully designed, and analytically rigorous study in which the primary outcome was a patient-centered measure of NH residents’ experience at EOL. Despite the challenges, it is imperative that we continue to try to improve patient-centered PC and EOL outcomes in the NH. First, we need to continue to test a variety of interventions to improve PC in this setting. A number of other studies testing novel PC interventions, such as telehealth PC consultations, are currently underway. We cannot know whether interventions will work until they are tested rigorously in the real-world setting with validated and responsive outcome measures.

We should expect some of these trials will have negative findings and continue to publish these findings so that we can learn from them. Second, we need to think about how to adapt already existing programs and infrastructure to improve the EOL experience of NH residents. In the United States, hospice is a model of care that has provided EOL care in the NH setting for decades. However, there have been concerns about the role of hospice in the NH setting, which has prompted attention from federal regulators. Concerns have focused on discrepancies between payments for hospice and the intensity of services required of NH residents, resulting in high profit margins for hospices and increased costs for Medicare. Recent changes to the Medicare hospice reimbursement structure are intended in part to address these issues. As hospice reform efforts proceed, it is critical that we ensure that access to NH hospice services is not compromised. Furthermore, we must also work to integrate PC models earlier in the disease course, with seamless transitions to hospice when appropriate.

Such an approach could help to ensure timely and cost-effective access to high-quality care for NH residents across the trajectory. Finally, at the policy level, NH regulation and quality measures should include metrics on palliative and EOL care for NH residents. In the United States, all NH residents must have an assessment, referred to as the Minimum Data Set, completed at regular intervals. Although some assessment items include measures in PC domains (e.g., pain and dyspnea), key elements are missing, such as documentation of preferences for EOL care and treatments.

Surveys of quality of care solicited from bereaved family members, such as those collected for NH decedents in the Veteran’s Affairs health care system, should be required of all NH decedents. Other quality metrics could include rates of PC involvement, hospice referral, and unwanted burdensome transitions to the hospital at the EOL. An increasing number of people are dying in the NH. Failing to acknowledge that most NH residents are approaching the EOL deprives them of opportunities to access high-quality palliative and EOL care. We need to continue to invest in rigorous and high-fidelity research, model development, and policies that help NH residents live their final months and years in comfort and dignity.

Paper For Above Instructions

The movement towards improving palliative care (PC) in nursing homes (NH) is crucial in meeting the needs of an aging population. As more individuals approach their final days in these settings, recognizing the importance of palliative care becomes paramount. This paper explores the current challenges and opportunities in enhancing end-of-life (EOL) care within nursing homes, emphasizing the need for systemic changes and innovative approaches to care.

First, it is essential to acknowledge the stigma surrounding death and dying in nursing homes. Traditionally, death in such settings is viewed negatively, often indicating poor-quality care. However, declining health and mortality are inevitable realities for a significant number of residents. In 2009, statistics indicated that over a quarter of deaths in the United States occurred in nursing homes, a figure projected to rise as the population ages (Teno et al., 2013). This demographic shift demands a change in how nursing homes approach palliative care, integrating it as a vital component of resident care rather than an afterthought or a sign of failure.

One major challenge faced in nursing homes is the lack of trained staff who are knowledgeable about palliative care principles and practices. The PACE study highlighted the need for improved training and education among nursing home staff to facilitate better EOL experiences for residents (Van den Block et al., 2019). Yet, the study also noted that improvements in staff knowledge did not significantly correlate with better resident comfort levels in the last week of life. This gap indicates that while education is necessary, it is not sufficient on its own. Nursing homes must address the broader systemic issues that contribute to the quality of EOL care.

Staff turnover presents another significant barrier to providing consistent and high-quality palliative care. High rates of turnover can disrupt the continuity of care, making it difficult for staff to develop relationships with residents and their families. Such relationships are crucial for understanding and addressing the unique needs and preferences of each resident (Collingridge Moore et al., 2019). To counteract this, nursing homes could implement strategies to enhance staff retention and foster a supportive work environment.

Additionally, integrating palliative care principles into existing nursing home structures is essential. Current regulations and assessment measures used in nursing homes, such as the Minimum Data Set, often do not adequately capture residents' preferences for EOL care or palliative services (Mor & Teno, 2016). Policymakers and healthcare administrators should collaborate to develop and implement assessment tools that capture these critical dimensions of care. Regular training for staff on palliative care protocols can also enhance their ability to address the complexities of EOL care in nursing homes.

Moreover, there is a need for innovative care models that bridge the gap between palliative care and hospice services. While hospice care has long provided EOL care in nursing homes, concerns have arisen regarding payment discrepancies and the intensity of care required (Vossius et al., 2018). Recent Medicare reforms aim to address these issues, ensuring that nursing home residents can access necessary services without compromising quality or incurring excessive costs. As these changes unfold, ongoing evaluation of hospice and palliative care integration within nursing homes will be vital.

Telehealth interventions represent another promising approach to enhancing palliative care in nursing homes. By utilizing technology to provide consultations and care planning, nursing homes can improve access to specialized palliative care services (Stephens et al., 2018). Implementing such programs can facilitate timely care interventions, ensuring that residents receive the support they need, and easing the burden on nursing home staff.

Furthermore, research into the effectiveness of various palliative care interventions is crucial. As illustrated by the PACE study, not all proposed interventions yield positive outcomes, and it is important to publish all findings, including negative results, to inform future efforts (Van den Block et al., 2019). This transparency is necessary for advancing the science of palliative care and understanding which strategies are most effective in nursing home settings.

In conclusion, improving palliative care in nursing homes requires a multi-faceted approach that addresses staff education, retention, regulatory frameworks, and innovative care models. By recognizing the importance of end-of-life care and implementing systematic changes, nursing homes can enhance the quality of life for residents in their final months and years. An ongoing commitment to research and quality improvement is essential in ensuring that all nursing home residents experience dignity and comfort during their final days.

References

• Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013.
• Vossius C, Selbæk G, Benth J, Bergh S. Mortality in nursing home residents: a longitudinal study over three years. PLoS One. 2018.
• Stephens CE, Hunt LJ, Bui N, Halifax E, Ritchie CS, Lee SJ. Palliative care eligibility, symptom burden, and quality-of-life ratings in nursing home residents. JAMA Intern Med. 2018.
• Van den Block L, Honinx E, Pivodic L, et al. Evaluation of a palliative care program for nursing homes in 7 countries: the PACE cluster-randomized clinical trial. JAMA Intern Med. 2019.
• Collingridge Moore D, Payne S, Van den Block L, Ten Koppel M, Froggatt K. Research, recruitment and observational data collection in care homes: lessons from the PACE study. BMC Res Notes. 2019.
• Mor V, Teno JM. Regulating and paying for hospice and palliative care: reflections on the Medicare Hospice Benefit. J Health Polit Policy Law. 2016.