Hospice Care in Assisted Living Facilities Versus at Home: Results of a Multisite Cohort Study.

OBJECTIVES: To compare residents of assisted living facilities receiving hospice with people receiving hospice care at home. DESIGN: Electronic health record-based retrospective cohort study. SETTING: Nonprofit hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. PARTICIPANTS: Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 85,581; 7,451 (8.7%) assisted living facility, 78,130 (91.3%) home). MEASUREMENTS: Hospice length of stay, use of opioids for pain, and site of death. RESULTS: The assisted living population was more likely than the home hospice population to have a diagnosis of dementia (23.5% vs 4.7%; odds ratio (OR) = 13.3, 95% confidence interval (CI) = 12.3-14.4; P < .001) and enroll in hospice closer to death (median length of stay 24 vs 29 days). Assisted living residents were less likely to receive opioids for pain (18.1% vs 39.7%; OR = 0.33, 95% CI = 0.29-0.39, P < .001) and less likely to die in an inpatient hospice unit (9.3% vs 16.1%; OR = 0.53, 95% CI = 0.49-0.58, P < .001) or a hospital (1.3% vs 7.6%; OR = 0.16, 95% CI = 0.13-0.19, P < .001). CONCLUSION: Three are several differences between residents of assisted living receiving hospice care and individuals living at home receiving hospice care. A better understanding of these differences could allow hospices to develop guidelines for better coordination of end-of-life care for the assisted living population.

Staying in the game: the 10-step approach to sustaining geriatrics education in hospitalists and subspecialty providers.

Geriatrics as a field has been fortunate to have the support of several philanthropic organizations to advance geriatrics education and training in the past two decades. Awardees of such grants were presented with unparalleled opportunities to develop new and innovative educational initiatives affecting learners at multiple levels and in multiple disciplines and specialties. The lessons learned from the Donald W. Reynolds Foundation initiatives about effect and sustainability are invaluable to the ongoing strategic development of geriatrics nationally. This article highlights successful educational initiatives developed at four institutions with past and current Donald W. Reynolds Foundation funding. Following an ice hockey playbook, this article identifies 10 strategies and initiatives to "stay in the geriatrics game" by training hospitalists and subspecialty providers. The authors' collective experience suggests that geriatrics educational initiatives can not only influence provider education, but also improve the care of older adults in multiple settings.

Implantable cardioverter defibrillator deactivation: a hospice quality improvement initiative.

BACKGROUND: Dying patients whose implantable cardioverter defibrillators (ICDs) continue to deliver shocks may experience significant pain, and the National Quality Forum has endorsed routine deactivation of ICDs when patients near the end of life. The overarching goal of this quality improvement project was to increase rates of ICD deactivation among hospice patients. MEASURES: ICD deactivation rates pre- vs. post-intervention; and clinicians' knowledge and confidence regarding ICD management. INTERVENTION: A multifaceted intervention included clinical tools, education, and standardized documentation templates in the electronic medical record. OUTCOMES: The proportion of patients whose ICD was deactivated increased after the intervention (pre- vs. post-intervention: 39/68, 57% vs. 47/56, 84%; odds ratio 3.88; 95% confidence interval 1.54-10.37; P = 0.001). Clinicians' knowledge and confidence regarding ICD management improved (pre- vs. post-intervention median questionnaire scores: 5 vs. 9 on a scale of 0 to 10; Wilcoxon signed-rank test Z = -5.01; P < 0.001). CONCLUSIONS/LESSONS LEARNED: A multifaceted intervention can increase rates of ICD deactivation among patients near the end of life.

Piloting a medical student observational experience with hospital-based trauma chaplains.

INTRODUCTION: Medical students have typically received relatively modest training in approaches for engaging the concerns of patients and families facing life-threatening situations and terminal illnesses. We propose that medical students would perceive benefits to their communication skills, understanding of the role of the chaplain, and knowledge of emotional and spiritual needs of grieving patients and families after shadowing hospital-based trauma chaplains whose work focuses on emergency department traumas and intensive care units. METHODS: The authors developed a pilot program in which medical students shadowed a trauma chaplain during an on-call shift in an urban level 1 trauma center. Students subsequently completed an evaluative survey of their experience. RESULTS: Of 21 participants, 14 (67%) completed the questionnaire. Students observed an average of 1.50 traumas and 3.57 interactions with patients or families. One-third of the students witnessed a death. More than 90% of respondents agreed or strongly agreed that (1) the program provided them with a greater understanding of how to engage patients and families in difficult conversations; (2) they learned about the chaplain's role in the hospital; and (3) the experience was useful for their medical education, careers, and personal development. About two-thirds (9/14) perceived that they learned how to discuss spirituality with patients and families. All recommended the experience be part of the medical school curriculum. DISCUSSION: Observational experiences with hospital-based trauma chaplains might be an effective nondidactic approach for teaching medical students effective communication with patients and families, collaboration with chaplains, and spirituality in patient care.

Geriatric palliative care: do medical students' narrative reflections after a hospice clinical experience link to geriatric competencies?

Since the Association of American Medical Colleges geriatric competencies were released, educators are striving to incorporate them into medical student curricula. The purpose of this study is to examine medical students' reflections after an interdisciplinary, hospice staff-precepted clinical experience, and whether these reflections relate to the geriatric competencies which focus on palliative care. From July 2010 to June 2011, 155 2nd- and 3rd-year medical students participated in a required, half-day hospice experience, with 120 (77%) submitting narrative reflections for analysis. The narratives were analyzed using the constant comparative method associated with grounded theory, followed by consensus-building in an iterative process, to identify themes. Six themes were identified from the analysis of student narratives: demonstrating a new or expanded knowledge of hospice care (79%, 95/120), developing new insights about self and others (74%, 89/120), changing attitudes toward hospice care (63%, 76/120), linking patient needs with appropriate team members (43%, 52/120), understanding patient goals of care (43%, 51/120), and discussing palliative care as a treatment option (27%, 32/120). The authors conclude that a brief, interdisciplinary, hospice staff-precepted clinical experience is an effective model to inspire medical students to reflect on geriatric palliative care. Students clearly reflected on the geriatric palliative care competencies of symptom assessment and management, and gained insight into the role of the hospice team members and how hospice care can be a positive treatment option. Future educators should think about building on this type of high impact learning experience, and developing items to measure application of knowledge gained.

Pilot test of a three-station palliative care observed structured clinical examination for multidisciplinary trainees.

Developing effective communication and symptom assessment skills is an important component of palliative care training for advance practice nurses (APNs) and other health care providers. The purpose of this project was to develop and pilot test a three-station palliative care Observed Structured Clinical Examination (OSCE) for APN students and physician fellows. Three stations included discussing goals of care, breaking bad news, and assessing delirium. Measures included the Interpersonal Skills Tool, Station Checklists, the OSCE Evaluation Tool, and a focus group to solicit learners' perspectives about the experience. Findings showed that learners evaluated the exercise as appropriate for their level of training and that standardized patients were convincing and provided helpful feedback. Learner self-evaluation means were significantly lower than those of standardized patient or faculty, and faculty raters demonstrated low interrater reliability. Initial evaluation suggests a three-station palliative care OSCE exercise is effective for multidisciplinary learners, although additional refinement is necessary.

End-stage renal disease: symptom management and advance care planning.

The prevalence of end-stage renal disease continues to increase, and dialysis is offered to older and more medically complex patients. Pain is problematic in up to one-half of patients receiving dialysis and may result from renal and nonrenal etiologies. Opioids can be prescribed safely, but the patient's renal function must be considered when selecting a drug and when determining the dosage. Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease. Nonpain symptoms are common and affect quality of life. Phosphate binders, ondansetron, and naltrexone can be helpful for pruritus. Fatigue can be managed with treatment of anemia and optimization of dialysis, but persistent fatigue should prompt screening for depression. Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea. Nondialytic management may be preferable to dialysis initiation in older patients and in those with additional life-limiting illnesses, and may not significantly decrease life expectancy. Delaying dialysis initiation is also an option. Patients with end-stage renal disease should have advance directives, including documentation of situations in which they would no longer want dialysis.

Palliative care for patients with dementia in long-term care.

Seventy percent of people in the United States who have dementia die in the nursing home. This article addresses the following topics on palliative care for patients with dementia in long-term care: (1) transitions of care, (2) infections, other comorbidities, and decisions on hospitalization, (3) prognostication, (4) the evidence for and against tube feeding, (5) discussing goals of care with families/surrogate decision makers, (6) types of palliative care programs, (7) pain assessment and management, and (8) optimizing function and quality of life for residents with advanced dementia.

Advance care planning and hospice enrollment: who really makes the decision to enroll?

PURPOSE: The purpose of this study was to assess patient participation in advance care planning (ACP) and the decision to enroll in hospice. METHODS: One hundred sixty-five family members of patients who died in hospice between January 2004 and September 2004 returned an anonymous survey (165/380; 43% response rate). RESULTS: Forty-nine percent of family members reported that the patient was not involved in the hospice enrollment decision. The majority of respondents (78%) reported one or more people helped make the decision to enroll in hospice. For patients reported as being involved in the decision to enroll in hospice (either independently or in a shared capacity) they were more likely to have cancer (odds ratio [OR] = 2.3, p = 0.02), die at home (OR = 3.3, p = 0.006), have a length of stay in hospice greater than 7 days (OR = 2.1, p = 0.03), and less likely to have dementia (OR = 0.43, p = 0.001). White respondents were more likely to report having ACP discussions with the patient about: feeding tubes (OR = 4.7; p = 0.001), cardiopulmonary resuscitation (CPR; OR = 3.9; p = 0.002), or mechanical ventilation (OR = 2.7; p = 0.02) than non-white respondents. White respondents were more likely than non-white respondents to report that the patient had a written advance directive (OR = 4.2, p = 0.001). DISCUSSION: These data indicate that some patients are not actively involved in the decision to enroll in hospice and that others, often physicians and family members, are making these decisions for the patient collaboratively. These data support the need for early education and interventions that assist patients and families in discussing ACP preferences and the need for greater understanding of how involved patients want to be with the decision to enroll in hospice.

Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.

Aspiration pneumonia is a leading cause of morbidity and mortality of elderly residents in long-term care facilities. The microflora present in the oral cavity because of poor oral hygiene has been associated with aspiration pneumonia. There is evidence that improved oral care can reduce the risk of developing aspiration pneumonia in the elderly. The purpose of this paper is to review aspiration pneumonia and provide oral health care guidelines in an effort to help reduce the risk of aspiration pneumonia in the elderly residing in long-term care facilities.