Nursing homes are the site of death for many elderly patients with incurable
chronic illness, yet dying nursing home residents have limited access to palliative
care and hospice. The probability that a nursing home will be the site of
death increased from 18.7% in 1986 to 20.0% by 1993. Dying residents experience
high rates of untreated pain and other symptoms. They and their family members
are isolated from social and spiritual support. Hospice improves end-of-life
care for dying nursing home residents by improving pain control, reducing
hospitalization, and reducing use of tube feeding, but it is rarely used.
For example, in 1997 only 13% of hospice enrollees were in nursing homes while
87% were in private homes, and 70% of nursing homes had no hospice patients.
Hospice use varies by region, and rates of use are associated with nursing
home administrators' attitudes toward hospice and contractual obligations.
Current health policy discourages use of palliative care and hospice for dying
nursing home residents. Quality standards and reimbursement rules provide
incentives for restorative care and technologically intensive treatments rather
than labor-intensive palliative care. Reimbursement incentives, contractual
requirements, and concerns about health care fraud also limit its use. Changes
in health policy, quality standards, and reimbursement incentives are essential
to improve access to palliative care and hospice for dying nursing home residents.