Home and Community Care Digest

Abstract

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.