Published in Woonsocket Call on May 10, 2015
A recently published study, by Brown University researchers, takes a look at end-of-life care in America’s nursing facilities, seeking to answer the question, is knowledge and access to information on palliative associated with a reduced likelihood of aggressive end-of-life treatment?
Brown researchers say when a nursing facility resident is dying, oftentimes aggressive interventions like inserting a feeding tube or sending the patient to the emergency room can futilely worsen, rather than relieve, their distress. While palliative care can pull resources together in a facility to provide comfort at the end of a resident’s life, the knowledge of it varies among nursing directors. A new large national study found that the more nursing directors knew about palliative care, the lower the likelihood that their patients would experience aggressive end-of-life care.
Susan C. Miller, professor (research) of health services, policy and practice in the Brown University School of Public Health and lead author of the study in the Journal of Palliative Medicine, published March 16, 2015, worked with colleagues to survey nursing directors at more than 1,900 nursing facilities across the nation between July 2009 and June 2010. The researchers hoped to learn more about their knowledge of palliative care and their facility’s implementation of key palliative care practices.
Knowledge Is Power
According to the findings of the Brown study, the first nationally representative sample of palliative care familiarity at nursing homes, more than one in five of the surveyed directors had little or no basic palliative care knowledge, although 43 percent were fully versed.
“While the Institute of Medicine has called for greater access to skilled palliative care across settings, the fact that one in five U.S. nursing home directors of nursing had very limited palliative care knowledge demonstrates the magnitude of the challenge in many nursing homes,” Miller said. “Improvement is needed as are efforts to facilitate this improvement, including increased Medicare/Medicaid surveyor oversight of nursing home palliative care and quality indicators reflecting provision of high-quality palliative care,” she said, noting that besides quizzing the directors the researchers also analyzed Medicare data on the 58,876 residents who died during the period to identify the type of treatments they experienced when they were dying.
When researchers analyzed palliative care knowledge together with treatment at end of life, they found that the more directors knew about basic palliative care, the lower likelihood that nursing facility residents would experience feeding tube insertion, injections, restraints, suctioning, and emergency room or other hospital trips. Meanwhile, residents in higher-knowledge facilities also had a higher likelihood of having a documented six-month prognosis.
The study shows only an association between palliative care knowledge and less aggressive end-of-life care, the authors say, noting that knowledge leads to improved care, but it could also be that at nursing facilities with better care in general, there is also greater knowledge. But if there is a causal relationship, then it could benefit thousands of nursing facilities residents every year for their nursing home caregivers to learn more about palliative care, the authors conclude.
Progress in Providing End-of-Life Care
Virginia M. Burke, J.D. President and CEO of the non-profit Rhode Island Health Care Association, said, “We were gratified that the authors found that most of the nursing directors who responded to their survey gave correct answers on all (43% of respondents) or most (36%of respondents) of the “knowledge” questions on palliative care. We were also gratified to see that the number of hospitalizations during the last thirty days of life has declined significantly over the past ten years, as has the number of individuals who receive tube feedings during their last thirty days. The need for continued progress is clear.”
Burke, representing three-quarters of Rhode Island’s skilled nursing and rehabilitation centers, adds, “It is not at all surprising that greater understanding of palliative care leads to better application of palliative care.”
The states’s nursing facilities are committed to providing person-centered end of life care, says Burke, noting that according to the National Palliative Care Research Center, Rhode Island’s hospitals are among the top performers for palliative care. “We suspect that our state’s nursing facilities are as well. We would be very interested in state specific results in order to see any areas where we can improve.”
Says spokesperson Director Michael Raia, of Rhode Island’s Health & Human Services Agency, “We need to provide the right care in the right place at the right time for all patients.”
When it comes to nursing facilities, Raia calls for reversing the payment incentives so that facilities are rewarded for providing better quality care and having better patient outcomes. He notes that the Reinventing Medicaid Act of 2015 reinvests nursing home reimbursement rate savings into newly created incentive pools for nursing homes and long-term care providers that reward facilities for providing better quality care, including higher quality palliative care.
Bringing Resources to Families
With caregiving one of AARP’s most important issues, it’s no surprise that the organization provides a great deal of guidance on palliative care, stressing that “it involves organizations and professionals coming together to meet a person’s needs both in terms of pain management, along with emotional and spiritual perspectives,” said AARP State Director Kathleen Connell.
Connell says that “It’s is truly a team effort in which nursing home staff become key players. The resources are important to patient with chronic and terminal issues. Their families need help, too. So it is important any time we learn more about ways we can address this very important healthcare need.”
Adds Connell, “In Rhode Island, I’m confident that we have nursing homes that are dedicated to easing the difficulty of this particularly stressful stage of life. They give patients and their families enormous comfort. We certainly applaud their compassion and hope the report is helpful anywhere it identifies a need for improvement,” adds Connell.
AARP’s Caregiving Resource Center (http://www.aarp.org/home-family/caregiving/) includes an End of Life section. Check out a specific palliative care resource at http://assets.aarp.org/external_sites/caregiving/multimedia/EG_PalliativeCare.html
To read the Brown Palliative Care Study go to http://online.liebertpub.com/doi/abs/10.1089/jpm.2014.0393.
Herb Weiss, LRI ’12 is a Pawtucket writer covering aging, health care and medical issues. He can be reached at firstname.lastname@example.org.