Providing End-of-life Care Increasingly Important in Long Term Care
Dr. Andy Kramer
Communication with elders and family members about end-of-life care is becoming more accepted and encouraged. As staff care for older and frailer residents in skilled nursing centers, becoming comfortable with, and respecting, end-of-life conversations has become essential.
According to a 2017 report from the Medicare Payment Advisory Commission, in 2013 and 2014, one in four long-term care (LTC) residents (defined as an admission of at least 100 days) died. Only 2 percent of LTC residents died in the nursing centers with the lowest mortality rates, and 46 percent died in centers with the highest rates. Thus, communities had very different levels of experience with deaths, resulting from the types and attitudes of the residents they admitted.
Amount of end-of-life care (defined as care of residents during their last six months of life) also varied greatly among centers. The share of end-of-life care averaged about 13 percent of LTC days across all centers. However, the range was 2 percent at the low end and 24 percent at the high end.
Thus, nursing centers were not alike when it comes to how much end-of-life care they provided. The centers with the highest share of end-of-life care days had 20 percent more hospitalizations relative to centers with average amounts of end-of-life care.
Most research has shown that elders prefer not to die in the hospital, and many prefer not to be hospitalized near the end of life. Not surprisingly, the nursing centers that were in the top 10 percent for use of hospice care had 11 percent fewer hospital readmissions on average.
The new regulations, effective Nov. 28, 2017, clearly support the resident’s right to make choices at the end of life: “The ability of a dying person to control decisions about medical care and daily routines has been identified as one of the key elements of quality of care at the end of life. The process of advance care planning is ongoing and affords the resident, family, and others on the resident’s interdisciplinary healthcare team an opportunity to reassess the resident’s goals and wishes as the resident’s medical condition changes.”
About 25 percent of Medicare dollars are consumed in the last year of life.
Five states (California, Colorado, Oregon, Vermont, and Washington) and the District of Columbia go even further with a Death with Dignity Act or End of Life Options Act. In these states, an individual can choose to receive a prescription for a lethal dose of medication, under designated circumstances. Nursing centers have been subject to legal liability for not honoring this choice.
A recent study found that about 25 percent of Medicare dollars were consumed in the last year of life, which is consistent with research findings over the past few decades. This finding was hailed as a good result, mostly because we often hear myths about health care expenditures at the end of life being higher than that.
In providing care at the end of life, however, the focus should not be on whether the cost is too much, or lower than we thought. Instead, we need to focus on providing end-of-life care that is what residents want for themselves and their loved ones.