Hospitals Nursing Homes

Maximizing utility for end-of-life care

Hospitals in Sacramento were concerned about the large number of nusring home transfers to its facility.  Were many of these tranfers unnecessary? Did patients with little chance of recovery benefit from these hospital stays?

To reduce end-of-life tranfers to hospitals from nursing homes, 3 Sacramento-area hospital systems and 18 nursing homes instuted the Preparing Residents for End-of-Life Plans and Respecting Endof-Life Decisions (PREPARED) project.  In the project, the hospital systems provided clinician educators with expertise in end-of-life care to work part of their time each week in nursing homes. The PREPARED intervention included provided advance care planning (ACP) education to patients as well as nursing home staff and administrators.

The study found that the initiative decreased hospitalization rates, increased nursing home as the the site of death, and improved perceptions of quality of care by family members.

How do family members perceive quality of care? The study shows that family members prefer the more intimate setting of a nursing home to a hospital, but this preference is likely conditional on a fixed death date.  By this I mean that if a family knew there loved one would die with certainty on a given date, the nursing home would be the preferred setting. If hospital care could extend the patient’s life, however, (i.e., more realistically not conditioning on death date) then family members may prefer to send their loved one to the hospital even though it is a less intimate setting.  A lot of these preferences may have to do with provider education. Providers who tell family members that their loved one has a chance (albiet small) of recover may be more likely to go the hospital route than those whose providers tell them there is basically no chance of recovery.

Further, most people would rather commit an error of commission than omission.  For instance, by not sending a loved one to the hospital, family members may feel guilt that they didn’t do all they could to save the patient.  However, sending the loved one to the hospital has its own risks (hospital acquired infections, complications, medical errors), but it seems that generally family members feel less guilty about death due hospital-related care.

Thus, although the study shows that family members are more satisfied when their loved one dies in a nursing home compared to a hospital, I do not believe that this is strong evidence of a long-term trend towards less hospitalization of terminally ill patients.

SourceKathy Glasmire and Kathleen Kerr. Be Prepared: Reducing Nursing Home Transfers Near End of Life. CHCF, March 2011.

1 Comment

  1. Providing the general public and nursing home staffs education
    regarding the difference between old-age and old-age, in end-of-life
    circumstances due to multiple end-stage-disease processes, is crucial if
    we are going to economically survive the aging baby boomers over the
    next two decades. In particular, the public desperately needs a clearer
    understanding of the difference between quality life and physiological
    life. The decision to pull the plug is seldom a relevant quality care
    issue for patient or family today, but the doctor’s ability for plugging
    in today’s expensive technology for maintaining meaningless,
    physiological life is a daily quality of care issue throughout our
    nation’s hospitals and nursing homes—Alan D. Cato MD, F.A.A.F.P.. Excerpted from The Medical
    Profession Is Dead and the Doctor Is “Critically ill!” by Alan D. Cato MD

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