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• W2078492785 abstract "For more than 3 decades I have practiced and taught geriatric medicine, mostly in the nursing home setting. For those not familiar with nursing home care in the early 1980s, it was almost entirely long-term palliative care, as rehab was carried out in the hospital setting. There were no do-not-resuscitate regulations, as it seemed clearly futile to try to resuscitate nursing home patients. When a patient appeared to failing, usually from multiple comorbid cognitive and physical issues, measures were put in place to ensure a comfortable and dignified death. Experienced physicians were a key factor in recognizing when patients would obtain little benefit from hospitalization and artfully communicated this to patients and their families. Hospice was in its infancy in the United States, having started in Great Britain a few decades earlier. Congress enacted legislation in 1982 for hospice benefits under Medicare A. Hospice care started for the terminal cancer patient in the United States, with the bulk of patients being treated in the home care setting. Hospice services, originally entirely from nonprofit entities, was invaluable in helping the dying patient remain at home, with inpatient units used for a small percentage who could not be cared for by family members. In the 1990s, some hospice patients started to enter nursing homes, being discharged from inpatient hospice units, unable to return to their home environment. A higher percentage of patients also carried noncancer terminal diagnoses. The entry of hospice into the nursing home seemed to be extraneous to me at the outset. Although the concept of knowledgeable and compassionate care at the end of life was laudable, it wasn't clear exactly what the role of the hospice staff was. After all, an RN is on duty 24 hours per day with support from LPNs and nurses' aides. Unroe et al 1 Unroe K.T. Cagle J.G. Dennis M.E. et al. Hospice in the nursing home: Perspective of frontline nursing home staff. J Am Med Dir Assoc. 2014; 15: 881-884 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar and her associates found approximately one-third of nursing home staff noted coordination problems with hospice. My personal experience would suggest that percentage is much higher among nurses. I found it interesting that both Unroe et al 1 Unroe K.T. Cagle J.G. Dennis M.E. et al. Hospice in the nursing home: Perspective of frontline nursing home staff. J Am Med Dir Assoc. 2014; 15: 881-884 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar and Swagerty 2 Swagerty D. Integrating palliative care in the nursing home: An interprofessional opportunity. J Am Med Dir Assoc. 2014; 15: 863-865 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar concluded that these data represented an opportunity for better coordination between hospice and nursing home staff. I would argue for the opposite view, that hospice, through a formal arrangement with an outside vendor, and the nursing home is inherently a poor match. Although there are several factors in play creating this mismatch, 3 are most important: (1) Basic philosophy and skill set of long-term care facilities, (2) evolution of the role of the hospice nurse over time, and (3) cost. Response to the Letter to the Editor by Matthew Raider, “Hospice in the Nursing Home: Perspective of a Medical Director”Journal of the American Medical Directors AssociationVol. 16Issue 5PreviewThe old idiom “don't throw the baby out with the bath water” applies to the use and misuse of hospice in the nursing home. Office of Inspector General reports and epidemiologic data suggest that hospice is often not properly used in long-term care (LTC) with increasing numbers of very long and very short hospice stays, high deficiency rates, nebulous diagnoses used for enrollment, and questionable effectiveness of LTC-hospice collaborations.1–4 However, as several authors have pointed out, hospice use in the LTC setting has been shown to improve several patient care outcomes and reduce cost at all time periods. Full-Text PDF Integrating Palliative Care in the Nursing Home: An Interprofessional Opportunity: Response to the Letter to the Editor – Dr Matthew RaiderJournal of the American Medical Directors AssociationVol. 16Issue 5PreviewDr Raider details several issues of concern that are well worth addressing. I generally agree with his position on a number of these issues, having also written my editorial from the perspective of a long-term care medical director and attending physician for the past 25 years. However, it should be noted that his focus was on whether hospices have a legitimate role in the nursing home, whereas I took the broader perspective of advocating that nursing homes must prepare for their compelling mission as “palliative care providers” so as to provide excellent palliative and end-of-life care to their residents. Full-Text PDF Response To Dr Raider's JAMDA Letter to the EditorJournal of the American Medical Directors AssociationVol. 16Issue 5PreviewExcellent palliative care can be provided with resources within the nursing home setting; however, we disagree with Dr Raider's characterization that this is the current default standard, and that hospice providers are somehow redundant or undermining quality nursing home care. In fact, one study of family members of deceased nursing home residents found that physicians failed to recognize and treat symptoms near the end of life, missed opportunities for advance care planning, and were not present enough in the nursing home to provide needed care. Full-Text PDF" @default.
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• W2078492785 title "Hospice in the Nursing Homes: Perspectives of a Medical Director" @default.
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