Sarah A. Wilson

The Challenges and Opportunities in Providing End-of-Life Care in Nursing Homes

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.

Family perspectives on dying in long-term care settings.

Dying is a central experience in the life of a family. Yet there are few studies of dying in long-term care and the role of a family. The dynamic relationships among families, staff, and residents in long-term care facilities related to the process of dying is an area where research is needed. As part of a larger study of death and dying in long-term care settings, 11 family members who recently had experienced the loss of a relative in the long-term care setting were interviewed. The purpose of this study was to describe family perspectives on death and dying in long-term care facilities and to discuss ways staff may be helpful to families in coping with the loss of a family member. Analyzing death and dying from the family perspective offers health care providers an opportunity to expand the understanding of the phenomenon of death in long-term care facilities and to incorporate care activities that families view as helpful. Major themes emerged from this study, including the caring behaviors of staff, participating in the dying process, and providing spiritual support. The themes and practice implications are discussed in this article.

Nursing interventions to promote dignified dying in four countries

PURPOSE/OBJECTIVES To describe nursing interventions to promote dignified dying as identified by nurses in four countries. DESIGN Cross-sectional survey design. SETTING Hospitals and clinics in Ethiopia, India, Kenya, and the United States. SAMPLE A convenience sample of 560 nurses who cared for dying patients in Ethiopia (n = 14), India (n = 229), Kenya (n = 36), and the United States (n = 281). METHODS Nurses who agreed to participate completed the International Classification for Nursing Practice Dignified Dying Survey. Responses to an open-ended survey question about the interventions nurses use to promote dignified dying were analyzed qualitatively. MAIN RESEARCH VARIABLES Nursing interventions. FINDINGS The Dignity-Conserving Care Model provided a framework to analyze nursing interventions used to promote dignified dying. Although some variation was found in the interventions used, nurses from all four countries identified interventions representing each of the three major categories of the model: illness-related concerns, a dignity-conserving repertoire, and a social-dignity inventory. CONCLUSIONS Nurses identified the holistic nature of the dying experience and the multiple interventions needed to promote dignity for dying patients and their family members. Palliative care is an area of practice that crosses healthcare settings, specialties, countries, and cultures. IMPLICATIONS FOR NURSING This study begins to identify specific interventions for future research and applies the Dignity-Conserving Care Model to further understand dignified dying from an international nursing perspective.

The effects of hospice interventions on behaviors, discomfort, and physical complications of end stage dementia nursing home residents

This project was guided by the question—what is the effect of hospice-oriented care on discomfort, physiological complications, and behaviors associated with dementia for residents of long term care facilities with an end stage dementing illness? Convenience sampling from three long term care facilities was used and 62 residents completed the project. The intervention was implemented through a four pronged approach: • Interdisciplinary development of the intervention strategies for the new hospice households; • Development of the households; • Use of a hospice nurse as a case manager; and • Education of staff A pretest-posttest experimental design with random assignment to groups was used. Two months after the interventions were implemented, there was a statistically significant difference in discomfort levels between the treatment and control groups (t = 3.88, p < .001). Even though the treatment group showed lower scores on the tool that assessed behavior problems, the differences were not large enough to be statistically significant (t = 1.44, p = .155). There was no difference in the number of physical iatrogenic problems between the treatment and control groups (t = .054, p = .957). Staff reaction to the project was positive with staff reporting greater job satisfaction and empathy, and describing a variety of improvements in residents.

Hospice and Medicare Benefits Overview, Issues, and Implications

Hospice care is based on a holistic philosophy that considers the physical, psychological, and spiritual dimensions of care for dying patients and their families. It is a family-centered approach and promotes death with dignity. The rapid growth of the hospice movement was in response to dissatisfaction with the care of the terminally ill and demands for death with dignity. Public support for the hospice was so strong that just 8 years after the first hospice was founded, it became a benefit under Medicare. The Medicare hospice benefit emphasizes home care and has shifted the burden of care to families. The restrictive nature of Medicare hospice rules influences who is eligible for hospice care. The Medicare benefit is not congruent with the holistic philosophy of hospice.