Skip to main content

Palliative Care Consultations in Nursing Homes: It Can (and Should) Be Done

Last station nursing home

by: Eric Widera (@ewidera)

One out of every four people living in the United States will die in a nursing home.  To say that access to palliative care is lacking for these individuals would be an understatement. What palliative care is delivered is too often limited to those who are eligible for and elected hospice care.

A study published in JAGS this week gives us some of the best evidence so far that palliative care can be delivered in this setting, and is associated with less hospitalizations and burdensome transitions.

A Study of Palliative Care in the Nursing Home

The study authors looked at data from two palliative care provider organizations that were subsidiaries of hospice agencies in order to identify nursing home palliative care consultations in North Carolina and Rhode Island.  Between the study years of 2005 to 2010, these two organizations were the only providers of palliative care consultations in the two counties in North Carolina and the six in Rhode Island where study nursing home were located.   The data from these patients were then linked to Medicare and MDS data.

The authors compared this group to a propensity score matched group to control for factors such as age, gender, race, gender, cancer or dementia diagnosis, functional and cognitive impairment, recent hospitalizations, nursing home characteristics, and DNR orders.
.
Ok, What Did They Find?

The authors ended up comparing 477 nursing home residents who died between 2006 to 2010 with initial palliative care consultations within 180 days of death against 1,174 propensity score–matched controls that did not receive these consultations from the same nursing homes.

Residents with palliative care consultations had:

  • Reduced hospitalizations in last 7 days of life, in last 30 days of life, and in the last 60 days of life
  • Reduced ED visits in last 30, and 60 days of life
  • Fewer burdensome transitions

Furthermore, earlier admission to consultation programs was associated with lower hospitalization rates in the last 7 days of life.


Lastly, the adjusted Medicare expenditures in the last 7 days of life were significantly lower for residents with initial consultations in the last 30 and 61 to 180 days of life than for controls.

The Take Home

In a closely related article in JPSM, the same authors found that nursing homes introducing specialty palliative care consults experienced greater overall reductions in end-of-life hospitalization rates compared to nursing homes not introducing consults.   Also, in another JAGS article, for every three nursing home residents that participated in an advance care planning intervention using specially trained nurses, two changed their documented treatment preferences.

Taking all of this data as a whole, it’s encouraging to see that palliative care can actually work in community nursing homes.   I have to wonder though, how many of our palliative care trainees get any meaningful experiences in nursing homes in order to prepare them to give these types of consultations?


Comments

Anonymous said…
We have such a model where nurse practitioners who are trained in palliative care are based in skilled nursing facilities. This provides on-site close relationships between the NP and the patient/family, staff, and attending physicians. Advanced Care Planning is expected, and symptoms management is ongoing. Transition to hospice occurs in real time. The common barriers are family, who often have unrealistic expectations, and the only way to influence them is through the process of developing a trust relationship over time. It is kind, caring, cost avoiding care.
Michael said…
This population lives in the shadows for most of our society-present GeriPal audience, notwithstanding. This validating article once again reminds me of how desparately mismatched resources and expertise are to the incredible unmet need for the modest skills and compasssion-in-action that high quality palliative care interventions bring.

We need development of more network capacity for palliative care services to be deployed nimbly to people with serious illness in nursing homes, specialty clinic, hospitals, and homes. The only thing that can drive the creation of that human infrastructure for caring will be favorable economics. The savings that come by investing in in the care of our fellow human beings approaching the completion of their life cannot be added to the profits of venture capitalists. Rather, they need to be reinvested in the creation of greater capacity for this valuable kindness.
Steven Radwany said…
Thank you, Eric. Very nice post as always.

From the HPM Program Requirements:

IV.A.3.c) Fellows should receive a long-term care experience at a skilled nursing facility, chronic care hospital, or children's rehabilitation center. (Detail)

The intent of this requirement is to encourage and assure just such an experience for all trainees. Whether individual programs have the capacity to meet the spirit of the requirement could be open to question, but hopefully most see the value and try...
Anonymous said…
How often do you palliative care consults in within your own VA nursing home?

I have found even where there is robust palliative care service, they often don't do many consults for veterans living within the VA Centers for Community Living.
Eric Widera said…
Great question Anonymous about the VA nursing home. One thing that the VA has led the way on is making sure that every medical center has a palliative care service. We do and we provide consults to our VA nursing home. We can definitely do more work there and there is need.

With that said, we are also realizing that the palliative care needs of Veterans living in community nursing homes are so very great. It's something that we are trying to figure out how to deliver, so if anyone has any suggestions would love to hear them. That's one of the reasons I loved this article as it is a guidepost.
Traci Cowan said…
This article is amazing and hits home.
We need education in our communities and public to make aware of the quality of life that hospice and palliative care can give. People have misconceptions concerning hospice and our VA elderly and skill nursing facilities need more palliative care. The need is so great but the knowledge needs to be introduced along with ways to make this happen. I would love to be involved in making this available to our VA seniors.
Will Grinstead said…
There is a familiar pitfall here--calling one nurse or NP a palliative care "program" is inaccurate and misleading as to the transdisciplinary nature of palliative care. A recent article on "palliative care" consults by a single team member in the ICU setting found this to actually cause harm to surrogates. We need to continue advocacy for all that palliative care is about--the whole team. Perhaps the authors addressed in the original article.

Popular posts from this blog

Lost in Translation: Google’s Translation of Palliative Care to ‘Do-Nothing Care’

by: Cynthia X. Pan, MD, FACP, AGSF (@Cxpan5X)

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life.  Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation.  It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

Elderhood: Podcast with Louise Aronson

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th.

We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody).

This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey as a geriatrician facing burnout, aging and death of family of Louise's members, insightful stories of patients, and more.

We focus therefore on the 3 main things we think our listeners and readers will be interested in.

First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"?

Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking?  We focus on Louise's…

Psychedelics: Podcast with Ira Byock

In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life.

Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously."

In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness.   Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

While you're reading, I'll just go over and lick this toad.

-@AlexSmithMD





You can also find us on Youtube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher
Transcript
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, I spy someone in our …