Steven Zweig

Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections

(See editorial comments by Dr. Joan Teno on pp 159–160)

Hospice and nonhospice nursing home residents.

OBJECTIVE To compare hospice residents in nursing homes with residents who are noted as end-stage, but not in hospice programs. DESIGN Descriptive comparison of the outcomes reported on Minimum Data Set (MDS) for all residents admitted to Missouri nursing homes in 1999. SETTING Nursing homes. PARTICIPANTS Residents of nursing homes designated as either hospice or end-stage on admission MDS. MEASUREMENTS Percentage of hospice residents having various conditions as compared with other end-stage residents. RESULTS/CONCLUSIONS Overall the clinical conditions of both hospice and nonhospice end-stage residents were similar. A greater percentage of hospice residents were found to have living wills, DNR orders, and cancer, and to be in moderate or severe pain. Hospice and nonhospice residents experienced similar time from admission to death or discharge (20 and 36 days, respectively). Based on the clinical condition of the two groups, it would appear that there are limited clinical reasons for the low utilization of the hospice benefit in nursing homes. The increased prevalence of advance care planning may lead toward use of hospice or may result from hospice enrollment. Hospice services seem to be thought of more frequently for residents with cancer and residents experiencing pain. Nursing homes must recognize their role as caregivers to the dying before palliative care is seen as a need for nursing home residents. Nursing homes need education in determining when a patient is appropriate for palliative care as only 4% are designated as end of life, and only 2% are shown to be receiving hospice care in hospice-contracted facilities.

Who cares for Missouri's Medicaid nursing home residents? Characteristics of attending physicians.

Objective: To describe the characteristics of physicians attending Medicaid recipients in Missouris certified nursing homes (NH).

A Profile of Residents Admitted to Long-Term Care Facilities for End-of-Life Care

INTRODUCTION Permanent placement in a Long-Term-Care (LTC) facility following hospitalization or when staying at home is no longer a viable option is the reality for a growing number of Americans. When death is imminent, the specialized knowledge and skill of the hospice team is required and accepted as an important component of end-of-life (EOL) care. The provision of appropriate care at the EOL is contingent on accurate identification of those residents who are approaching the final stage of life. This study describes the prevalence, profile, and survivorship of residents admitted to LTC facilities, using the Minimum Data Set (MDS) designation of being at the EOL. METHODS A descriptive, correlational, retrospective cohort design was used to analyze all residents admitted to certified LTC facilities with hospice contracts in Missouri in 1999. Variables for analysis were selected from the MDS items that are clinically relevant for those residents at the EOL, for example, pain, incontinence, skin condition, activities of daily living (ADLs), depression, and weight loss. In addition, items regarding advance directives, use of special treatments, and diagnoses were selected because they are important to the care of residents at the EOL. RESULTS Of 492 eligible facilities, 159 were confirmed as providing hospice care. Of 9615 admissions to these facilities, 432 (4.5%) met the EOL care definition; half of these were receiving specialist hospice care. The EOL residents were distinguishable in terms of symptoms. Median survival time for EOL admissions was 33 days. At 6 months, only 17% of EOL admissions remained in the facility. CONCLUSIONS Residents designated as EOL who are admitted to LTC are a distinct group from other new residents, with identifiable needs requiring specialist attention. Accurate recognition that EOL is imminent is required for the development of appropriate strategies and resources for care.

The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision.

To determine the relative importance of factors influencing physicians to use tube feedings in patients lacking decision‐making capacity.

Using Mortality Risk Scores for Long-term Prognosis of Nursing Home Residents: Caution Is Recommended

BACKGROUND Determining prognosis for nursing home residents is important for care planning, but reliable prediction is difficult. We compared performance of four long-term mortality risk indices for nursing home residents-the Minimum Data Set Mortality Risk Index (MMRI), a recent revision to this index (MMRI-R), and the original and revised Flacker-Kiely models. METHODS We conducted a prospective cohort study in one 92-bed facility in Missouri. Participants were 130 residents who received a Minimum Data Set assessment from May through October, 2007. We collected the Minimum Data Set variables needed to calculate the mortality risk scores. We determined 6- and 12-month mortality for included residents. Using each mortality risk score as the sole independent predictor in logistic models predicting mortality, we determined discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic) for each model. RESULTS In our sample, discrimination was 0.59 for both the MMRI and the MMRI-R. Discrimination of the original Flacker-Kiely model was 0.69 for both 6 months and 1 year and 0.71 and 0.70, respectively, for the revised model. Model calibration was adequate for all models. CONCLUSIONS Performance of four models that predict long-term mortality of nursing home residents was fair. In our population, the Flacker-Kiely models had similar and markedly better discrimination than either the MMRI or the MMRI-R.

Community Attitudes And Knowledge About Advance Care Directives

Background: Patients and their physicians are increasingly being encouraged to discuss end-of-life decisions. The purpose of this study was to enhance understanding of the public’s attitudes and knowledge about medical decision making and advance care directives. Methods: Eight focus groups of community members discussed their understanding of and attitudes about advance care directives. Transcripts of these discussions were analyzed using coding categories created from the transcripts. Results: Eighty-three people attended the focus groups. Most discussions of advance care directives involved family members in the setting of family or personal illness. Elderly persons commonly confused wills with living wills. Most who had given advance directives did so either to make others follow their wishes or to ease family burdens. Among the great variety of reasons for not using advance directives was a perceived lack of personal relevance, as well as conceptual, moral, and practical difficulties. Participants were divided about whether it was appropriate for physicians to initiate discussions about life-sustaining care with their patients. We discerned three themes affecting individuals’ opinions about personal decision making about advance directives: (1) trust in family and the medical system, (2) need for control, and (3) knowledge about advance directives. Conclusions: Although living wills are advocated by many authorities, and many of our participants endorsed their use, our participants also cited numerous cautions and impediments to their use. As the role of advance care directives changes, physicians will need to be aware of their patients’ perceptions, as well as the leplities of these documents.

Experience with implementation of a quality improvement project for the care of nursing home residents.

The purpose of this column is to discuss innovations and quality improvement efforts in a variety of long-term care settings. These issues are of importance to healthcare professionals as our nation faces the burgeoning growth of the aging population, creating increased demand for improved and innovative long-term care services. This column is coordinated by Marilyn J. Rantz, PhD, RN, FAAN, NHA, e-mail: rantz@missouri.edu

Returning from the Total Institution to a Home Environment: A Journey for Birthing and Dying

The medicalization of both birth and death transformed the settings of care for these two important transitions in life. As the events moved from the home into a hospital, they became part of what Erving Goffman referred to as the “Total Institution.” Recently, attempts have been made to overcome the problems of these total institutions with specialized rooms. Using a medical sociological perspective, this article addresses the similarities in the establishment of birthing rooms and dying rooms. This demedicalization of the birth and death experience is a result of the gradual rejection of the total institution and presents an opportunity to seek characteristics of home in these environments.

Improving the quality of nurse assistants in nursing homes: report of an attending physician survey and an AMDA Symposium.

OBJECTIVES To describe views of attending physicians regarding nurse assistants as part of a multidisciplinary seminar on nurse assistants at the 1997 American Medical Directors Association (AMDA) Annual Symposium. DESIGN Mailed survey. PARTICIPANTS AMDA members. MEASUREMENTS Attitudes regarding nurse assistants and the role of attending physicians with regard to enhancing the role of nurse assistants. RESULTS Respondents rated the importance of quality nurse assistants with a mean of 4.85 and a mode of 5 (5 being very important). They also thought it was important for the medical director attending physicians to support, train, or otherwise assist in the professional development of nurse assistants (mean 4.07, mode 5). Respondents recommended enhanced training, reduced workload, increased salary and benefits, and building more effective relationships as strategies for improving the quality of care provided by nurse assistants. CONCLUSION Physicians can be important in enhancing the role of the nursing assistant. Some activities may include acknowledging the nurse assistant, providing support and feedback, and supporting policy changes that enhance continuity, nonhierarchical management, and creative training programs.