End-of-Life Care in Nursing Homes with Greater versus Less Palliative Care Knowledge and Practice.

Background: Many older adults in nursing homes (NHs) lack palliative care (PC) access; but little is known about whether access to PC knowledge and practice (beyond hospice) impacts residents' care.

Objective: The study objective was to evaluate how differing levels of NH PC knowledge and practice are associated with residents' end-of-life health care use.

Methods: In 2009/10 we surveyed a stratified random sample of U.S. NHs and asked directors of nursing (DONs) PC knowledge and practice questions from Thompson and colleagues' validated PC Survey. This study includes 1981 NHs with complete survey responses and the 58,876 residents who died in these facilities between July 2009 and June 2010. Medicare resident assessment (minimum data set [MDS]) and claims data from July 2009 through June 2010 were used to determine outcomes and a NH's hospice use. Multivariate logistic regressions examined whether residing in NHs with higher PC scores was associated with documented six-month prognoses and receipt of aggressive treatments, including hospital and emergency room (ER) use in the last 30 days of life.

Results: Controlling for NH hospice use, being in a NH with higher PC care knowledge scores was associated with residents having a higher likelihood of documented six-month prognoses and lower likelihoods of having feeding tubes, injections, restraints, suctioning, and end-of-life hospital and ER use. Being in a NH with higher PC practice scores was associated with a lower likelihood of having feeding tubes and ER visits.

Conclusion: Policies and advocacy promoting the development of NH PC knowledge and practices could potentially improve care and reduce hospital and ER use.