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A simple information and communication intervention between a patient and physician can increase hospice referral rates among nursing home residents, increase their families' ratings of end-of-life care, and may decrease use of acute care resources, according to an article in the July 13, 2005, issue of JAMA.1


Approximately 25% of residents with daily cancer pain receive no pain medications, and residents are often transferred to an acute care setting to receive aggressive treatment in the last weeks of life. Families often express dissatisfaction with the end-of-life care their relatives receive in nursing homes. Nursing home residents in hospice care are more likely to receive better pain management, have pain assessed appropriately, and undergo lower rates of inappropriate medications and physical restraint use. Despite its benefits, however, only one in four nursing home residents enrolls in hospice care before death.


David Casarett, MA, MD, from the Philadelphia Veterans Affairs Medical Center, Philadelphia, and colleagues conducted a randomized trial of nursing home residents and their decision makers to determine whether promoting communication about hospice would increase hospice enrollment and improve the quality of end-of-life care. For the intervention, the researchers interviewed residents and/or their surrogate decision makers to identify those whose goals and needs for care and treatment preferences made them appropriate for hospice. The physicians of residents classified as appropriate for hospice were notified and asked to authorize a hospice informational visit. The trial was conducted from December 2003 to December 2004. Residents were followed up for 6 months or until death.


Of the 205 residents in the study, 107 were randomly assigned to receive the intervention, and 98 received usual care. Those in the intervention group were more likely than usual care residents to enroll in hospice within 30 days (20% vs 1%) and to enroll in hospice during the follow-up period (25% vs 6%). Intervention residents received more hospice care than did usual care residents (average: 64 vs 14 days), although intervention residents were not more likely to be enrolled in hospice at the time of their death (36% vs 38%). These intervention residents had fewer acute care admissions and spent fewer days in the acute care setting. Families of intervention residents rated the residents' care more highly than did the families of usual care residents (on a 1-5 scale, average: 4.1 vs 2.5).


"If there is a surprise in these findings," the authors write, "it is that such a simple, inexpensive, and easily exportable intervention can contribute so much to improving care. As Americans spend more time in nursing homes near the end of life, it will become increasingly important to emphasize simple, low-cost interventions like this one that can help to ensure that residents and their families have access to the best possible quality of care."






1. Casarett D, Karlawish J, Morales K, Crowley R, Mirsch T, Asch DA. Improving the use of hospice services in nursing homes. JAMA. 2005;294:211-217. [Context Link]