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.
“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.
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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.
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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.
SOURCE: http://bit.ly/2fIgd8L JAMA Internal Medicine, online
November 28, 2016.
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