Steven Littlehale

A few weeks back, I attended my high school reunion. I found myself on the dance floor shaking a tail feather with Linda, a friend from 35 years ago who always made me laugh. Time didn’t diminish her sense of humor, but our conversation took a surprising turn when she segued from a quick reminiscence to an impassioned statement about dignity at end of life.

Linda decided, at age 53, to go back to school to become a nurse. She’s passionate about elder care and described the profound honor of aiding at the bedside during one’s passing. Linda didn’t know that in high school I made the decision to become a nurse, nor did she know that I’ve devoted my entire career to the betterment of our elders, especially at end of life.

It’s not morbid to talk about death, even on the dance floor at your high school reunion. Yet in the nursing home, ground zero for frail elder care, we don’t regularly or consistently have these most important conversations about end of life wishes, expectations, hopes and dreams. Do you ever wonder why? Many factors that characterized early American culture have seemingly reversed the reality surrounding, and our acceptance of, human mortality.

For one, the commercialism and escapism of a post-war American society certainly emphasized youth and vitality, marginalizing aging and banishing a consciousness of our inevitable mortality. For another, the many customs and superstitions that have been introduced in the last century due to immigration have discouraged earlier views of death which were more realistic and pragmatic. I personally believe that these widespread theories, which value a longer life over a more fulfilling one, provide a cultural context for our industry’s current reimbursement system, which incentivizes volume over quality, and “minutes” over resident-centered care.

As Madison Avenue figures out how to make aging “sexy” (read: profitable) and we transition to the new PDPM payment system, I am hopeful that the long-term care industry will learn to embrace these difficult conversations around end of life.

In June of 2014, I published an article in McKnight’s titled “For whom does the bell toll? MDS knows.” The MDS is an excellent way to predict future mortality of your residents. In this article I shared the outcomes of PointRight’s study where we used MDS to identify end-of-life residents. Sixty-nine percent of the 7.2 million residents who scored highest on this MDS-mortality scale expired within six months. This same scale was equally successful in predicting mortality post-SNF discharge to the community.

Identifying residents at end of life is a moral imperative. I fervently believe that if you are working in this space, you have this obligation to systematically identify residents at end of life and diligently work to elicit their voice and unique care needs. Without much effort, a compelling business case could also be made explaining how the benefits of doing such go well beyond the obvious and extend into survey, Five-Star and quality measures.

We recently completed an analysis of over four million MDS assessments and focused exclusively on those residents who triggered three long-stay quality measures: Activities of daily living, antianxiety/hypnotic, and worsened independent movement. Remember that hospice utilization and less than six months to live are exclusions for triggering these measures (end-stage prognosis (J1400) and/or hospice (O0100K2)).

The goal of our analysis was to identify how many of the residents that triggered these select QMs also scored high on our MDS-based mortality scale. Otherwise stated: How many residents triggered these QMs when they should not have? The results were as follows:

Long stay outcome — ADL (2% of those who triggered were at end of life); Antianxiety/Hypnotic (11%), Worsened Independent Movement (6%).

Imagine that this was your facility (and not an average of approximately 2,500). Would you like to see the elimination of the 11% proportion of your residents that triggered for the antianxiety/hypnotic QM? Proper identification of end-stage prognosis or hospice care would make that happen.  

Incidentally, in this same study, we found that 4.3% of short-stay patients who returned to the hospital were at end of life, and as I previously shared in a McKnight’s article published last year, more than 16% of long-stay residents who were at end of life were sent to the hospital.

So, kind readers, it’s not morbid to talk about death. While it might not be your personal calling like it is for Linda, it is our obligation to advocate for our patients and residents, which includes systematically identifying end of life, so their final days can be spent to the fullest.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.