Medical management decisions in nursing home patients. Principles and policy recommendations

The ethical principles of medical decision making are inherently the same for nursing home residents, who represent an increasingly large segment of the population, as they are for other adult patients. In practice, however, a number of considerations require specialized application of these principles in nursing homes. Notably, a large proportion of nursing home patients are at high risk for morbid and mortal events yet are incapable of expressing medical management preferences due to dementia and confusion. Policies and procedures regarding medical decisions for nursing home patients are needed. We present and discuss a policy for patient care in nursing homes based on recommendations of a national biomedical ethics committee. This policy, which may be adapted for use in specific institutions, explicitly discusses the principles of care and their application in nursing homes. It also encourages prospective decision making and provides advance care directives for patients making and provides advance care directives for patients and their decision-making surrogates to do so.     

Cardiopulmonary resuscitation policies and practices. A statewide nursing home study

We determined the prevalence of written cardiopulmonary resuscitation policies in North Carolina nursing homes and evaluated their content according to predetermined criteria. Questionnaires were mailed to 236 state-registered facilities. Two hundred nine nursing homes (88.5%) responded to the questionnaire; 83% reported having a written policy, and half (86 nursing homes) provided copies. Nine of ten nursing homes reported that cardiopulmonary resuscitation was performed at their institution, and a similar number (92%) permitted physician orders restricting cardiopulmonary resuscitation. Written policies were systematically compared with 10 model criteria. Policy content varied substantially. More than half of the policies contained provisions for authorization, informed consent, documentation, competency, review, and applicability of do not resuscitate orders. Less than half contained criteria for autonomy, treatment alternatives, dignity and quality of care, and patient identification. Nursing homes that had written policies were newer, larger, and for-profit; had a greater proportion of skilled nursing care beds; and were more likely to have both Medicare and Medicaid certification. The variations in these policies place nursing home residents at risk for having important personal rights limited or ignored. Inclusion of these 10 policy criteria in a comprehensive cardiopulmonary resuscitation policy would represent an important step toward enhancing the quality of decision making by nursing home residents.     

Advance care planning in nursing homes: correlates of capacity and possession of advance directives

PURPOSE: The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. DESIGN AND METHODS: The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors. RESULTS: Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged. IMPLICATIONS: Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.     

Potential cost savings in residential care for Alzheimer's disease patients.

Data from a 1996 cross-sectional study examining the costs of care for Alzheimer's Disease patients are used to estimate the potential cost savings that could result by substituting assisted living for nursing home care for AD residents with health profiles that appear to be manageable within assisted living facilities that specialize in dementia care. Results indicate that up to 13.9% of nursing home costs could be saved, making such a service substitution an attractive alternative in the provision of residential care for certain categories of AD patients.     

Nursing Home Entry: Meaning Making by Relatives

In-depth interviews are being conducted with relatives of nursing home residents regarding their experience of nursing home entry. This paper reports on preliminary analysis of the texts generated by interviews with nineteen relatives. Grounded in hermeneutic phenomenology, the study explores and describes these experiences. Seven themes are described which assist understanding of the experience from the decision making through to nursing home entry.     

Family Advocacy Roles and Highly Dependent Residents in Nursing Homes

A developing critique has questioned the practical utility of user rights policy initiatives for highly dependent residents of nursing homes. This paper seeks to extend this critique to the advocacy roles that families have been accorded within the policy initiatives. The discussion is based on a qualitative research study of family participation in six aged care units. The paper argues that the capacity of families to act as advocates for highly dependent nursing home residents is limited by the their weak position within the organisations and the complexity of their relations with staff. It questions both the applicability and the appropriateness of rights models which do not take sufficient account of the structure and meaning of care.     

Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions

OBJECTIVE: To determine the appropriateness of transfers to acute care hospitals from a nursing home. DESIGN: Nursing home and hospital records of all the nursing home residents during the 3-year study period were reviewed retrospectively to determine: number and type of transfers; problems identified in the nursing home justifying the transfers; diagnoses made at the hospitals; length of hospital stays; outcome of hospital visits. SETTING: An 80-bed public nursing home. SUBJECTS: 112 residents in the nursing home over the 3-year study period. MAIN OUTCOME MEASURES: Based on the decision of the hospital physician, those transfers resulting in hospital admissions were considered appropriate. As well, transfers to the emergency room with return to the nursing home without hospital admission were also judged to be appropriate if the problems required diagnostic and therapeutic procedures not available in the nursing home. RESULTS: During the 3-year study period, 55 residents (49%) were transferred a total of 102 times. An average of 26% of patients were transferred each year. Direct admissions to acute hospitals accounted for 17% of the transfers, transfers to the emergency room with subsequent admission for 34%, and transfers to the emergency room with subsequent return to the nursing home without admission for 45%. Four percent of patients transferred died in the emergency room. On the basis of the outcome measure, 7% of all transfers could have been diagnosed and treated in the nursing home and were considered inappropriate. CONCLUSIONS: The majority of transfers from this nursing home to acute-care hospitals were appropriate.     

Relatives' Experiences of Nursing Home Life: Characterised by Tension

Indepth interviews were conducted with nineteen relatives of nursing home residents regarding their experience of nursing home entry. The study is interpretative and themes were identified from the data which assist understanding of this experience. In a previous paper I reported on the experiences from decision making to entry. This paper reports on the experiences after entry.     

Retention and survival of hostel residents – a 12 year study

Abstract Background: The admission of a proportion of disabled people to hostels is inevitably followed by their transfer to nursing homes. Our hypothesis was that such admissions are justified in terms of quality of life and the cost to the community, notwithstanding the necessity of subsequent transfer. Aims: To test this hypothesis by measuring the retention and survival times of residents in hostel and in nursing home; to consider the relevance of these factors to the future policy of the two institutions. Methods: A retrospective study was made of 159 residents admitted over a period of 12 years to a hostel with 32 places. Times spent in the hostel and in the nursing home were recorded. Probabilities of survival in hostel and in nursing home were calculated according to the Kaplan-Meier method. Comparison with the expected survival of a matched cohort of the total population was determined. Estimation was made, using the SAS software package, of the likely number of places needed in nursing homes for residents following transfer. Results: Although the majority of hostel residents eventually needed nursing home care, a worthwhile proportion of their total institutional time (approximately two-thirds) was spent in the hostel. Ongoing support from the personnel in a geriatric service is likely to increase retention time in the hostel. Because of the ultimate outcome for the majority of residents, planning for hostel care should include consideration of places needed in nursing homes.     

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Surrogate decision makers' attitudes towards tube feeding in the nursing home

In the nursing home, a widely accepted medical practice is to recommend the initiation of long term tube feeding in residents with eating difficulties. However, frequently the nursing home resident has dementia, lacks decision-making capacity, and has no advance directives to guide the physician and the family member(s). Therefore, the family member or another surrogate decision maker has to make the difficult decision of whether or not to consent to the placement of a feeding tube. We surveyed 50 English speaking surrogates of nursing home residents who were on a feeding tube for at least 6 months. Each surrogate was contacted by telephone and was administered a 16-item structured questionnaire. Statistical analyses included frequency distributions, and the Wilcoxon signed rank test for two related samples. Most surrogates rated the residents' quality of life as poor or extremely poor. Yet, 78% of the surrogates perceived tube feeding to be beneficial, 62% would repeat their initial decision to initiate tube feeding, and 68% would not consider removal of the feeding tube. Their leading concerns were medical complications, tube feeding's impact on each resident's quality of life, and adequacy of nursing care. The surrogates were satisfied with their initial decision for the placement of a feeding tube despite their perception that there was no improvement in the quality of life of the residents. The surrogates may have viewed tube feeding as a life prolonging measure.     

Hospitalization patterns and palliation in the last year of life among residents in long-term care

PURPOSE: This study compared patterns of care, including hospitalization, during the last year of life for a group of residents in institutional long-term care. These subjects were either implicitly or explicitly in palliative care modes versus those who remained in active treatment or blended care. DESIGN AND METHODS: The study used a retrospective chart review and both quantitative and qualitative methods of data collection and analysis to examine indepth the end-of-life experiences of 41 nursing home residents who died in the nursing care unit of one large continuing care retirement community during an 18-month period. RESULTS: Most residents die in palliative care modes, but their movement into palliation with comfort care and symptom management is often slowed by indecision or inaction on the part of key decision makers, interrupted by aggressive acute care, or delayed until the last few days of life. IMPLICATIONS: Transitions from active curative care to palliative care are important for residents in permanent long-term care placements. Improved end-of-life care requires more attention to these transitions and to the decisions that residents, their families, and care teams are called upon to make.     

PATHWAYS TO A MAINSTREAM NURSING HOME: A SURVEY OF CHINESE,GREEK AND ANGLO AUSTRALIANS

A survey of the family carers of 21 Chinese, 26 Greek and 25 Anglo Australian nursing home residents compared their aged relatives' pathways to a mainstream nursing home. The Greek aged were older and more dependent at placement while the Chinese were relatively young. Communities differed in terms of those involved in the decision making process, family reactions to the decision, reasons for selection of a home and use of services prior to placement. Community similarities included the types of event which precipitated placement, the categories of people initiating discussion of placement and the aged people's reactions to the decision.     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.     

Experts recommend minimum nurse staffing standards for nursing facilities in the United States

The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained.     

Advance care planning and end-of-life care for hospitalized nursing home residents

OBJECTIVES: To describe advance care planning (ACP) and end-of-life care for nursing home residents who are hospitalized in the last 6 weeks of life. DESIGN: Constant comparative analysis of deceased nursing home resident cases.SETTING: A not-for-profit Jewish nursing home. PARTICIPANTS: Forty-three deceased residents hospitalized within the last 6 weeks of life at a tertiary medical center. MEASUREMENTS: Trained nurse reviewers abstracted data from nursing home records and gerontological advanced practice nurse field notes. Clinical and outcome data from the original study were used to describe the sample. Data were analyzed using the constant comparative method and validated in interviews with a gerontological advanced practice nurse and social worker. RESULTS: The analysis revealed distinct characteristics and identifiable transition points in ACP and end-of-life care with frail nursing home residents. ACP was addressed by social workers as part of the nursing home admission process, focused primarily on cardiopulmonary resuscitation preference, and reviewed only after the crisis of acute illness and hospitalization. Advance directive forms specifying preferences or limitations for life-sustaining treatment contained inconsistent language and vague conditions for implementation. ACP review generally resulted in gradual limitation of life-sustaining treatment. Transition points included nursing home admission, acute illness or hospitalization, and decline toward death. Relatively few nursing home residents received hospice services, with most hospice referrals and palliative care treatment delayed until the week before death. Most residents in this sample died without family present and with little documented evidence of pain or symptom management. CONCLUSION: Limiting discussion of advance care plans to cardiopulmonary resuscitation falsely dichotomized and oversimplified the choices about medical treatment and care at end-of-life, especially palliative care alternatives, for these older nursing home residents. Formal hospice services were underutilized, and palliative care efforts by nursing home staff were often inconsistent with accepted standards. These results reinforce the need for research and program initiatives in long-term care to improve and facilitate individualized ACP and palliative care at end of life.     

Staff Perceptions of Communication Difficulty among Nursing Home Residents

Hearing and vision impairment are prevalent among older people in long-term care, contributing to their communication difficulties. Data on 44,012 nursing home residents were obtained with the Resident Classification Instrument, a rating scale designed to determine each resident's need for nursing and personal care, and hence entitlement to Federal funding. Comparison with related studies suggests that nursing home staff in Australia underestimate the contribution hearing loss makes to the communication difficulties of the residents in their care. An alternative approach to the assessment of the communication needs of residents is recommended to permit a more accurate assessment of needs.     

An outbreak of giardiasis in a nursing home with evidence for multiple modes of transmission

During a 6-w period from 20 April through 7 June 1986, an outbreak of giardiasis occurred in residents and employees of a nursing home and children participating in day care at the nursing home. Eighty-eight cases of giardiasis (defined by presence of clinical symptoms or results of stool examination) were identified from groups associated with the nursing home including 35 in nursing home residents, 15 in children in day care, and 38 in employees (including kitchen staff and child care providers). Multiple modes of transmission of Giardia lamblia, including food-borne and person-to-person transmission, occurred for these groups. Evidence of transmission by food included a significant association between sandwich consumption and illness in nursing home staff (P = .04) and a significant lack of illness among nursing home residents who consumed only a pureed diet (P = .007), where all food items are cooked before serving. The primary case among the food handlers, whose illness began in mid-April, had an infected child in the day care center. Person-to-person transmission is supported by a significant association between illness and physical contact with children from the day care facility through an "adopted grandparent" program (P = .03). This is the first reported outbreak of giardiasis in a nursing home, and these findings have implications for disease control in other facilities that combine child day care and care of the elderly.     

Physician Attitudes Concerning Anticoagulation Services in the Long-Term Care Setting

Objectives: There is little experience in the use of specialized anticoagulation services in the long-term care setting. Even less is known about physician attitudes regarding these services. To examine this issue, we surveyed physicians caring for nursing home residents in a sample of long-term care facilities located in Connecticut. Methods: We surveyed physicians providing care to nursing home residents of a convenience sample of 21 Connecticut nursing homes. (These facilities had participated in a quality assessment and improvement project on preventing strokes in nursing home residents with atrial fibrillation.) Physicians were requested to complete a structured questionnaire about the challenges to managing nursing home residents on warfarin therapy and preferences concerning the use of an anticoagulation service to manage warfarin therapy in this setting. Results: A total of 245 physicians were asked to participate in the survey, and 114 (47%) responded between November 5, 1999 and January 14, 2000. Of the 114 physicians who returned the survey, 91 reported that they currently cared for residents in long-term care facilities and thus completed the questionnaire. The majority of respondents agreed or strongly agreed that an anticoagulation service would reduce the workload on physicians, increase the costs of care for nursing home residents on warfarin, and increase the percent of time that nursing home residents on warfarin are maintained in the target therapeutic range. Most physicians disagreed or strongly disagreed with statements suggesting an anticoagulation service would decrease the costs of care for nursing home residents on warfarin, reduce the liability of the prescribing physician, interfere with their ability to care for patients on warfarin therapy, and reduce the risk of warfarin-related bleeding. Forty-five percent of respondents agreed with a statement that an anticoagulation service would intrude on physician decision-making. Only about half (53%) of the respondents indicated that they would or might utilize an anticoagulation service for managing their long-term care patients on warfarin. Conclusions: Use of a specialized anticoagulation service to manage warfarin therapy is a systems-level approach with the potential to improve the effectiveness and safety of this treatment. Physician skepticism regarding the usefulness of anticoagulation services will only be overcome by subjecting this approach to rigorous evaluation and by assuring physicians of their ongoing involvement in decision-making regarding warfarin therapy in their patients.