Improving the Use of Hospice Services in Nursing Homes. A Randomised Controlled Trial.
Casarett D, Karlawish J, Morales K, Crowley R, Mirsch T and Asch DA;
Commented by , 22 Aug 2005
Background
Critiques of end-of-life care suggest the hospice movement should extend its principles of care beyond its traditional remit – patients with cancer in the community. Do patients and carers in nursing homes want this, and is it beneficial?
Aims
To increase hospice utilisation and improve the quality of end-of-life care in nursing home residents, whose goals and preferences are consistent with a hospice approach.
Methods
The study recruited residents and their "surrogates"/relatives from 3 diverse nursing homes in Philadelphia. Residents were excluded if they were already receiving hospice care, or if the resident was too cognitively impaired to complete the interview and did not have a surrogate.
Two research assistants conducted a standardised interview with consenting residents/surrogates, including the Mini Mental State Examination (MMSE), need for palliative care services, the Global Distress Index (GDI) and preference for cardiopulmonary resuscitation/a life-prolonging approach, versus a palliative approach.
Intervention
In the intervention group, results of each interview were faxed to the resident’s primary care doctor, who was asked to reply by fax, indicating whether he/she would like the nursing home to arrange a hospice visit.
Residents/surrogates in the control group were given a brief description of hospices and simply told that they could learn more about hospice care from their doctor. The main outcome measure was thus hospice enrollment.
Follow Up
Residents were followed up for 6 months or until death. For those residents who had died, surrogates were asked to rate quality of care in the last week of life using the Toolkit Afterdeath Survey and a 5-point rating scale.
Results
Of 400 eligible residents, 14 died; 14 were already receiving hospice care; 26 could not complete the interview plus had no surrogate. Of the remaining 343, 138 residents/surrogates refused consent, leaving a total sample size of 205 (60%).
Participating residents were similar to all residents at the 3 sites in terms of age, gender, ethnicity etc. 32 interviews were conducted only with the resident, 45 with both resident and surrogate, and 128 with surrogate alone.
Residents in the intervention group were more likely to get hospice care than in the control group (21/107 versus 1/98; P < 0.001), as well as having less hospital admissions and spending less time in hospital (mean days 1.2 versus 3.0; P = 0.03). End-of-life experience, as rated by surrogates 2 months after death, was also significantly better in the intervention group.
Dr Seymour's comments
This study shows how a simple communication intervention can improve the quality of end-of-life experience and decrease inappropriate resource utilisation.
The intervention is quick, cheap and easy to administer, and potentially transferable to other long term care settings, though clearly in Philadelphia the 3 nursing homes selected had good relationships with the local community hospice, which had capacity to manage nursing home residents.
One of the problems with end-of-life care is that it is often not thought about, or discussed, until the last minute, by which time it is too late for patients or their surrogates to exercise true choice. The benefits of hospice care may be greater for those patients referred earlier.
This study is of interest to hospice, nursing home, and primary care clinicians, but is it of any interest to (old age) psychiatrists? 65% of participants in this study had MMSE scores between 0-9, ie., had profound cognitive impairment, and the literature suggests that up to 80% of hospice patients develop delirium.
If the hospice movement wishes to extend its remit, it needs to be more inclusive of patients with Alzheimer’s Disease and other dementias, many of whom are already using their services without a dementia diagnosis being made.