Based on numerous studies,
5,20-22 it is believed that increased availability of hospice care in nursing homes can lead to improved end-of-life care, including better pain assessment and management, for dying nursing home residents. Without adequate assessment, pain cannot be managed. Miller et al
5 provide evidence that hospice enrollment for dying nursing home patients results in superior pain assessment and management. Patients enrolled for more than 8 days had a higher chance of pain being assessed, and they were five times more likely to receive an opioid during their last 2 days of life. Furthermore, compared with findings of a previous study by Miller et al,
21 a higher proportion of both hospice and nonhospice nursing home residents had more pain assessments completed, suggesting a beneficial collaborative effort.
5 Wu et al
22 confirm that hospice positively affects and improves the assessment of symptoms on both an individual and facility basis.
In the nursing home setting, however, barriers such as the prevalence of dementia, the multiplicity of pain problems, and greater sensitivity to drug adverse events pose greater difficulty in assessing and managing pain.
7 Teno et al
4 note that in the general nursing home population, 56% of residents are either moderately or severely cognitively impaired. Nursing staff's astuteness and reliance on changes in patterns of residents' behavior enable detection of pain or other changes in residents' condition.
14 Mitchell et al
23 found patients with advanced dementia who were admitted to nursing homes had greater functional disability, more behavior problems, and more often had total parenteral nutrition at the end of life than patients who were cared for at home. Healthcare providers did not recognize that patients were dying and infrequent referrals were made to hospice. Dying patients were frequently hospitalized, underwent burdensome treatments, and had distressing symptoms that were potentially treatable when death was imminent.
23
Baer and Hanson
20 reviewed family perceptions of hospice. Respondents rated quality of care for pain and other physical symptoms as good or excellent for 64% of patients before hospice services; after initiation of hospice, this rating increased to 93% of patients. For emotional and spiritual needs, the quality of care was excellent or good for 64% of patients before and 90% of patients after hospice was initiated. Families did not perceive nursing home and hospice staff as duplicative. The median estimated added daily monetary value of nursing home hospice was $75, with 45% of family respondents estimating this value at $100 or more per day.
20