Scant high-quality research on hospice care in nursing homes

A new evidence review finds that there's scant high-quality research on the best comprehensive strategies for nursing homes hoping to ease the suffering of older patients through hospice care.

Researchers only found three studies - all from the United States - that met their criteria to be included. While the findings offer "potentially promising results," the studies aren't strong enough to justify recommending their individual approaches, said review lead author Dr. Sue Hall, a palliative care specialist at King's College London.

Still, the studies suggest that elements of the strategies such as teams of specialists and partnerships between nursing homes and hospice care services "are a key aspect" of care, Hall said.

Hospice care, the focus of the review, refers to care for patients who are dying. It focuses on relieving suffering — including physical, emotional and spiritual pain — and has become increasingly popular in the United States in recent decades.

At the same time, a higher percentage of people are dying in nursing homes, said Marianne Matzo, a professor of palliative care nursing at the University of Oklahoma. The problem, she said, is that "they were not built or set up as a place where people are going to end their lives, especially in these numbers."

The authors of the Cochrane Library review sought to determine whether there is evidence to support specific hospice approaches at nursing homes for seniors.

The review was published by The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The review authors found little reliable research into approaches to hospice care in nursing homes. The three studies they analyzed comprised 735 participants, of whom 75 percent to 81 percent were women.

There were some helpful findings. Family members felt better about care for their relatives after the patients took part in a program that aimed to identify those who would benefit from hospice care. Dying patients with dementia seemed to have less discomfort when they were part of a program that included special units for them, education for staff and special individual plans of care. However, the review authors said there are questions about the reliability of both findings.

Two studies found that hospice care strategies improved the delivery of care, but they did not determine if patients actually fared better. None of the studies examined the cost effectiveness of the approaches used.

Cost, of course, is a crucial factor in health care. In the United States, current payment systems can hurt high-quality care at nursing homes, said Dr. R. Sean Morrison, director of the National Palliative Care Research Center at Mt. Sinai School of Medicine.

"If I have a patient in New York who develops an infection in the nursing home, I know that all the data tell me if I treat them in the nursing home, the patient is less likely to develop confusion or delirium, less likely to develop a pressure ulcer, more likely to recover," Morrison said. "But if I transfer the patient to the hospital, Medicare pays for the ambulance and the entire hospitalization and everything else, and I can keep that bed empty at that nursing home and still be paid by Medicaid for that bed and not have to pay for nursing staff or for it to be cleaned."

Hall, the review lead author, called for high-quality studies into comprehensive hospice strategies in nursing homes. She acknowledged that there is still a need to agree on how to figure out whether a strategy works. However, she said, funders will need to pay for the research.