A palliative care focus
Diane Meier, M.D.
Palliative care, specialized medical care focused on treating the symptoms and stress of serious illness, should be the standard of practice for all elderly people in skilled care settings.
Yet many facilities are falling short on delivering the high quality care their residents deserve. Limited resources, overwhelmed and undertrained frontline staff and beleaguered leadership are all part of the problem. Inadequate pain management in nursing homes is common and well-documented, as are pressure ulcers, the use of physical and chemical restraints and feeding tubes.
Little attention is given to advance care planning, hospice referrals are often made too late or not at all, and repeated avoidable hospitalizations are widespread. Hospitalizations regularly result in medication errors, hospital-acquired infections and other adverse events and poor communication of new care plans.
Tomorrow's nursing homes must strive to be different. The integration of palliative care into nursing homes offers a compelling solution. The goals of palliative care address patient's needs for communication, decisions about treatment, relief of distressing symptoms (such as pain from pressure ulcers or arthritis) and support for caregivers.
Different from hospice care, palliative care can be delivered at the same time as life-prolonging disease treatment, and eligibility depends on need rather than on prognosis.
Further, for most serious illnesses other than cancer, life prolonging and palliative treatments are often one and the same. Consider diuretic therapy for fluid overload in heart failure. It prolongs life and it palliates by relieving shortness of breath.
LTC palliative care delivery
A growing body of evidence from diverse settings (cancer centers, community-based cancer care) shows that palliative care not only improves the quality of care. It increases patient and family satisfaction and can help prolong survival. The proposed drivers of reduced mortality associated with palliative care include reduced iatrogenesis (reduced exposure to harmful medical care such as hospitalizations, which are estimated to be the third-leading cause of death in the U.S.), crisis prevention through effective pre-emptive symptom management, and reduced depression (depression is an independent predictor of mortality in every disease in which it co-occurs).
As a side effect of providing better quality care, palliative care also reduces 911 calls, emergency department visits and hospitalizations, resulting in decreased healthcare costs.
The dominant models of palliative care delivery in nursing homes take on one or several of three different approaches. The first is engagement of outside palliative care consultants on the request of the nursing home's medical director, the resident's attending physician, or the nursing home's director of nursing. The advantages of this model include that palliative care is available for all nursing home residents, and that it is available without additional costs to the nursing home (palliative care consultants bill Medicare part B fee-for-service).
The second model of delivery is nursing home employment of its own palliative care team and training in palliative care knowledge and skills of its own frontline staff. This is an increasingly popular model with many advantages as daily contact between clinicians and nursing home residents helps to promote care that is based on a keen understanding of the patient's goals and preferences, as well as timely response to clinical changes. Examples of this model include the Comfort Matters approach developed in Phoenix, AZ (www.comfortmatters.org) and the practices of the Green House and Eden Alternative nursing home models.
The third model involves partnerships between hospice agencies and nursing homes in the same communities. This practice has increased rapidly in the last 10 years, and has raised some concerns about use of a benefit meant for the dying for residents with uncertain prognoses who “fail to die on time” and place the hospice at risk of government accusations of fraud and abuse. Studies show that nursing homes with higher hospice penetration tend also to have better palliative care practices (such as access to opioid analgesics) for all residents, whether on hospice or not. This is presumably related to greater staff awareness of techniques for pain and symptom management, as well as addressing emotional and spiritual needs.
There is little room for argument that the solution to providing higher quality care in nursing homes is greater integration of quality palliative care for a patient population for whom this care should be the standard of practice.