Approximately one-quarter of individuals die in a nursing home yet, in spite of this large number, families are often unhappy with the end-of-life care their relatives received. Hospice care is an alternative to the standard end-of-life care, yet few nursing home residents enroll in it before death. Through a randomized controlled trial, this study seeks to determine if the enrollment rate in hospice care would be higher with increased access, and if this is a higher quality of care alternative. Nursing home residents with more access to hospice care were observed to be more likely to enroll in it. Families of individuals in hospice care reported higher quality of care in end-of-life care. Based on these study results, hospice care can prove to be a lower cost, higher quality of care alternative for end-of-life care in nursing homes.

Background: Given the rapid aging population in North America and across the globe, there has been increasing amounts of research devoted to end-of-life care for nursing home residents. Approximately one-quarter of individuals die in a nursing home, yet despite this number, families are often unhappy with the end-of-life care their relative received. In recent years, there has been a movement to implement hospice care as a means to improve the quality of end-of-life care in nursing homes. Few nursing home residents enroll in hospice care before death, yet this study hypothesizes that the enrollment rate would be higher if physicians discussed hospice care with the residents and their families. This study also seeks to determine if increased hospice care utilization will improve the quality of end-of-life care received by nursing home residents, whose goals for care reflect those of hospice care.

Methods: This was a randomized control trial, conducted from December 2003 to December 2004, of 205 nursing home residents and their surrogate decision makers from three facilities in the United States. Residents were excluded if they were already involved in hospice care of if they were too cognitively impaired to be interviewed and did not have a surrogate decision maker to answer for them. Structured interviews were conducted to assess if the resident was appropriate for hospice care based on if they: 1) expressed the need for comfort as a goal for care; 2) refused both cardiopulmonary resuscitation and mechanical ventilation; and 3) identified at least one need for palliative care. Following these interviews, the residents were randomized into two groups. In the intervention group, the physicians of those residents who had been identified as hospice-appropriate were notified and asked to assign hospice care for their patient. In the usual care group, hospice appropriateness assessment was conducted in the same fashion, however it was not communicated to the physicians, and instead the resident and decision-maker were given a brief description of hospice services and the option to discuss further should they be interested. Residents were followed up for six months, or until death. If the resident died, the decision maker was asked, two months post, to evaluate the quality of the end-of-life care.

Findings: Of the entire sample, 107 residents were assigned to the intervention group and 98 to the usual care group. There were no significant differences in age, ethnicity, sex and mortality rates in the two groups. However, hospice enrollment rates within 30 days and in the entire follow-up period were both higher in the intervention group (20% and 25% respectively) versus the usual care group (1% and 6% respectively). Intervention residents received, on average, more days of hospice care than the usual care (64 days versus 14 days). Decision-makers of those residents who died rated the care received in the last week of life significantly higher in the intervention group than in the usual care group.

Conclusions: The results of this study indicate that increasing the awareness of the availability of hospice care can make it easier for individuals to access it. It was observed that there was a higher likelihood of hospice enrollment when the physician was made aware that their patient was hospice appropriate, compared to when only the residents and their families were made aware. Furthermore, it was observed that families were significantly happier with the quality of the end-of-life care received in hospice care. Hospice care can prove to he a higher-quality alternative for end-of-life care, and these findings are therefore important given the increasing demand for nursing home care in Canada.

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

Comments

Anton Hart wrote:

Posted 2015/02/13 at 10:34 AM EST

Sometimes you need to be a witness to understand the benefits of a service. Hospice in Peterborough, Ontario was noble, magnanimous and dedicated in caring for Maxine -- my friend and sister in law.