Expert offers ways to improve hospice access
As increasing numbers of older Americans spend their last days in a nursing home, it’s important for nursing home staff, as well as hospice providers, to identify nursing home patients who might qualify for a hospice placement, an end-of-life care expert says. Hospices often cite examples of how nursing home patients are referred to hospice care too late in their dying process to receive the most benefit from what hospice and palliative care can offer.
"The issue is how well are we caring for individuals dying in nursing homes," says Edward Vandenberg, MD, CMD, an assistant professor of geriatrics at the University of Nebraska Medical Center in Omaha. Vandenberg spoke about identifying terminal patients among the nursing home population at the Living a Good Life at the End of Life conference, held March-April 1, 2005, in Lincoln, NE. The conference was sponsored by the Nebraska Hospice and Palliative Care Association and other health care organizations.
"It becomes very important when so many people may plan their last few days there to know how to improve that quality of care," Vandenberg says.
Quality improvement studies in nursing homes have identified various ways to enhance care, but one item that stands out is teaching staff how to identify the patient who is going to die despite the best curative efforts, Vandenberg notes. "Those individuals sometimes have experienced undue suffering from repetitive curative attempts," he explains. "An example is the person who has end-stage Alzheimer’s disease who gets repetitive pneumonia, going to the hospital to receive all treatments," Vandenberg says. "Then in another month the person goes through the same sequence again."
One of the ways quality of life could be improved for this individual is for someone to identify this person as someone who would benefit more from a palliative approach than from aggressive curative care, he adds.
Seek opinions of experienced staff
A first step toward identifying patients for whom it’s time for a hospice referral or a shift to palliative care is to solicit the gut feelings of experienced staff, Vandenberg says. "Never expect the newly trained individual to tackle this," Vandenberg says. "But the experienced nursing home employee will have this gut feeling from a collection of tangible and objectified elements and intangible, non-objectified elements."
For instance, experienced staff can be assisted in trusting their intuition about patients by suggesting they ask themselves this question: "Will I be surprised if this person dies during the next six months?" Vandenberg says. "And if I wouldn’t be surprised, then the next question is, Am I doing everything I can to keep this person comfortable, or is that comfort being pushed aside in favor of more painful curative treatment that wouldn’t work anyway?’" he adds.
The next step is to examine goals and care plans at quarterly care conferences with patients and their families, Vandenberg says.
If a patient is repeatedly hospitalized, this might be a time to discuss a change in care with the family. Also, staff might wish to discuss family members’ comments or impressions about the patient, because often a first clue that a nursing home patient is dying will come from a family member who asks, "Do you think he’s dying?" Vandenberg suggests.
"Some things an experienced staff person might notice is if a person is going back and forth to the hospital with repetitive aspiration pneumonia, and each time the person is coming back worse," Vandenberg says. "Or maybe the person has pressure ulcers you can’t heal despite your best attempts, or maybe the person is losing weight or has lost the ability to do activities of daily living."
A third step is for a physician to use a terminal prognosis tool to confirm staff and physician impressions about a patient’s prognosis, Vandenberg says.
There are good prognosis tools available that were developed based on evidence-based procedure studies, including tools for predicting prognosis in chronic obstructive pulmonary disease patients, cancer patients, and dementia patients, Vandenberg says.
"If nursing home staff feel a patient is reaching that point of futility, but they need affirmation of their hunch, then they can use these tools, looking at a variety of parameters that the tool asks them to check and see if their hunch is right," he says. "There may be a few staff members at the care planning meeting who say, I wonder if we’re doing anything good for old Bill and his dementia,’ and then they can use the tool."
Most important, health care providers need to be alert to changes that might be a sign that a nursing home patient has reached the stage where a hospice referral or a switch to palliative care is needed, instead of aggressive curative care, Vandenberg says. "The goal is to improve the quality of their end-of-life care in these facilities," he adds.
As increasing numbers of older Americans spend their last days in a nursing home, its important for nursing home staff, as well as hospice providers, to identify nursing home patients who might qualify for a hospice placement, an end-of-life care expert says.
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