November 29, 2016
By Lisa Rapaport
(Reuters Health) - Nursing homes that send fewer residents to the hospital at the end of life might do a better job of communicating with families about the pitfalls of aggressive interventions than other facilities, a recent U.S. study suggests.
At the end of life, hospital stays for seriously injured or ill nursing home residents typically offer little hope of improving quality of life or changing outcomes for the better, researchers note in JAMA Internal Medicine, online November 28.
"We found that nursing home staff at all facilities encountered the same barriers to avoiding potentially burdensome hospitalizations, but that staff at low-hospitalizing facilities did two things very differently from those at high-hospitalizing ones," said lead study author Dr. Andrew Cohen of Yale University in New Haven, Connecticut.
"They avoided decision-making algorithms and did not send patients to the hospital by default when an acute event occurred, and they viewed it as their role to try to change families' minds when they requested a hospitalization that was unlikely to be beneficial," Cohen added by email.
While previous research has found hospitalization rates generally tend to be lower at nonprofit nursing homes or at places with well-used hospice programs, less is known about what factors might influence the odds of hospital stays at the end of life at individual facilities, Cohen said.
To figure out what might happen inside individual nursing homes to impact hospitalization rates, researchers analyzed data from detailed interviews with staff at eight facilities with some of the highest and lowest hospitalization rates in Connecticut.
Altogether, the study included interviews with eight directors of nursing, seven facility administrators, six social workers, two physicians, five advanced practice clinicians and three other staff members.
All of the participants recognized that nursing home residents were sometimes hospitalized for potentially burdensome care and identified some barriers that could make it difficult to avoid these transfers.
Participants at facilities with high hospitalization rates described algorithms used to determine if hospitalization was needed in individual cases with wide latitude given to families to request transfers even in cases when it might not help patients.
By contrast, at nursing homes with low hospitalization rates, participants said staff had the ability to be directly involved in decision making in each case and to disagree with families requesting transfers if clinicians thought residents wouldn't benefit, the study found.
The study is small and qualitative, so it doesn't prove how any given strategy for determining which hospitalizations are warranted would directly impact how many residents wind up in the hospital, the authors note.
It's also hard to get a complete picture of how hospitalizations happen without also interviewing family members who play a key role in this process, said Dr. Gary Winzelberg, a palliative care researcher at the University of North Carolina at Chapel Hill who wasn't involved in the study.
"Family members want their loved ones to receive quality care, and the responsibility of health professionals is to promote communication about the residents' care goals in the context of their medical condition and available options," Winzelberg said by email.
"The responsibility for decision-making regarding hospitalizations should be shared among health professionals and family members," Winzelberg added. "I'm concerned about the notion of changing families' minds."
While shared decision-making can help avoid unnecessary treatment at the end of life, advance planning is also crucial, said Dr. Joan Teno, a palliative care researcher at the University of Washington who wasn't involved in the study.
"Our previous national research found that institutions that adopted a culture of advance care planning had lower rates of terminal hospitalizations," Teno said by email.
Among other things, patients and families may consider creating a legal document known as an advanced directive that specifies what types of interventions should be done, and which ones should be avoided, at the end of life. This may include opting against ventilators, feeding tubes or other mechanical support.
JAMA Intern Med 2016.
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