Hospice referral rates increase with intervention

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 issue of JAMA: The Journal of the American Medical Association.

"At least one in four Americans dies in a nursing home, and considerable evidence indicates that nursing home residents do not receive optimal end-of-life care," background information in the article states. Approximately 25 percent 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 relative receives in nursing homes. Nursing home residents receiving hospice care are more likely to receive better pain management, have their pain assessed and have 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, M.D., M.A., 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 treatment. 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 six months or until death.

One-hundred seven of the 205 residents in the study 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 percent vs. 1 percent) and to enroll in hospice during the follow-up period (25 percent vs. 6 percent). Intervention residents received more hospice care than 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 percent vs. 38 percent). These intervention residents had fewer acute care admissions and spent fewer days in the acute care setting. Families of intervention residents rated the resident's care more highly than the families of usual care residents did (on a 1-5 scale, average: 4.1 vs. 2.5).

"The results reported herein show that a simple communication intervention can improve the quality of end-of-life care and decrease resource utilization by promoting earlier access to hospice care in nursing homes," the authors write. "If there is a surprise in these findings, 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 becomes 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."