Paper
Thursday, July 22, 2004
Palliative Care in Nursing Homes: Advance Directives and Events at the End-of-Life
Neville E. Strumpf, PhD, RN, C, FAAN and Cheryl Monturo, MSN, APRN, BC. School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
In the US < 20-25% of all deaths (500,000) occur annually in nursing homes (NH) or shortly after transfer to a hospital. NH residents have limited access to palliative care (PC). Objective: The purpose of the parent study was to implement an integrated PC Program as part of routine activities in the NH, and to evaluate its impact on residents and staff. A secondary aim was to examine the occurrence of nutritional treatment decisions (tube feeding –TF) within advance directives (AD) compared to utilization of TF in the last month of life. Design: Quasi-experimental. Population: Data were collected from 6 for profit NH in Maryland from 1999-2001. Four homes served as the intervention homes and two functioned as controls. Intervention/Outcome: The intervention consisted of PC education, consultation and interdisciplinary team development. We analyzed the following outcomes: Assessment and treatment of physical and emotional symptoms, attitudes of NH staff, events/treatments at end-of-life, and process implementation and culture change. Methods: Data were collected at baseline, during and following the intervention, using a PC screen, events at end-of-life worksheet, and field notes. Findings: At time of death, intervention homes had more residents with AD than control (p 0.01). Of those residents in intervention homes with AD (30%), 83% requested no TF. In 90% of documented events in the last month of life, a resident’s wishes were honored to forego TF. No resident with a documented weight loss was treated with TF. Conclusions: Visible successes included capacity to implement PC and to achieve positive outcomes, especially in those settings with stable leadership and commitment to project goals. Implications: Long-term, successful integration of PC in NH requires: Health care policies encouraging PC; reimbursement incentives recognizing that PC requires skills and resources; and pubic demand for PC as a reasonable expectation in every NH.
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