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Invited Commentary
Nov 12, 2012

Aligning Prognosis, Patient Goals, Policy, and Care Models for Palliative Care in Nursing HomesComment on “Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life”

Author Affiliations

Author Affiliation: Division of General Medicine, Virginia Commonwealth University, Richmond.

Arch Intern Med. 2012;172(20):1580-1581. doi:10.1001/2013.jamainternmed.592

Using the Health and Retirement Study database, Aragon and colleagues1 offer new insights into patterns of service use as older persons approach life's end. Major differences were observed in proportionate rates of hospice use in nursing homes for those who were community dwellers and subsequently died in the nursing home after using the Medicare skilled nursing facility (SNF) care benefit (19.3% of them had hospice care) compared with substantially fewer persons who died in a nursing home without first using the SNF benefit (44.5% of them had hospice care). Another notable finding was that almost half of 1081 community-dwelling decedents who used the SNF benefit died in a nursing home.

In this study, prior expectation of impending death in these decedents was prevalent among the SNF users (69.7%) and among those not using the SNF benefit (56.5%). Therefore, awareness of the burden of advancing chronic illness was evident in most patients and was more prominent among the SNF users. Furthermore, those using SNF services had more prior use of home health care, also suggesting some preexisting frailty trajectory that is the predeath pattern of almost half of Medicare beneficiaries.2

We have known since the National Long-Term Care Demonstration in the 1970s and before then that frail individuals who are able to live in the community with advanced chronic illness will usually stay there until death if they can and that they tend to make limited use of nursing home care. This would comport with the findings in this study. The results may in part reflect some underlying differences between the comparison groups in goals, expectations, and preferences that are not entirely captured by the measured variables.

In this analysis, the prevalence of dementia is surprisingly low at 28.5% compared with most frail populations who use institutional care. Although there was a small difference in prevalence between the SNF and non-SNF groups, cognitive impairment is not a factor in the adjusted predictive models. I wonder whether cognitive impairment may be underreported in the original data, as is often true in data sets that do not include direct clinical patient assessment. Dementia is an important driver of nursing home use, hospice use in nursing homes for patients with advanced dementia is low,3 and the many problems with setting appropriate goals4 and providing compassionate care that considers the prognosis in this subpopulation are solidly established.5

Reflecting on this study, about half of the SNF users did not die in the nursing home and ultimately went home, despite having significant frailty. We must all carefully avoid rushing to judgment and imposing end-of-life care protocols when reasonable vitality and quality of life remain, despite chronic illness burden. Patients continue to regularly surprise me in this respect, and physicians' professional credibility is compromised if they cannot recognize potential vitality in frail individuals when it exists.

Extensive clinical experience with almost 20 nursing homes and reported data support the observation that most patients in nursing homes are managed by physicians other than those who treated them in the hospital and other than their established primary care physicians. It is well documented and painfully evident in clinical practice that the handoff between physicians is often weak or nonexistent during transitions in care settings, and the logistics of matching visiting family and busy physician schedules in the nursing home setting to develop new connections can be challenging. In caring for patients who are approaching the end of life, there is a need to establish a trusting relationship and to have conversations, which can be time consuming. To make confident estimates about prognosis, these discussions also require that the physician has a good understanding of the prior condition of the patient and of evaluations that have been previously conducted. The process may require multiple encounters in the nursing home to establish a clear and optimized understanding of prognosis and goals of care, and a developed skill set on the part of the physicians who are involved is necessary. Continuity of care and the processes required to resolve complex issues are often fractured in contemporary health care, resulting in care that is ultimately not what many reasonable persons would choose.

The use of the hospice benefit improves the quality of end-of-life care processes for many patients in nursing homes because the needed clinical skills and availability of nursing home staff members are variable and may be insufficient for optimal palliative care. The findings in this study indicate a need for additional attention to trajectories, goals of care, and payment policy in the context of long-term care. Without doubt, the SNF benefit is too often used on admission to nursing homes for patients in whom the expected outcome is death because of incentives for the facility and financial burdens on the family that come from using the Medicare hospice benefit at the outset of nursing home care. Clinical practice and health care policy should perform better in this context, and this ultimately ties back to alignment of incentives.

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Article Information

Correspondence: Dr Boling, Division of General Medicine, Virginia Commonwealth University, PO Box 980102, Richmond, VA 23298-0102 (pboling@mcvh-vcu.edu).

Published Online: October 1, 2012. doi:10.1001/2013.jamainternmed.592

Conflict of Interest Disclosures: None reported.

Aragon K, Covinsky K, Miao Y, Boscardin WJ, Flint L, Smith AK. Use of the Medicare posthospitalization skilled nursing benefit in the last 6 months of life [published online October 1, 2012].  Arch Intern Med. 2012;172(20):1573-1579
Lunney JR, Lynn J, Hogan C. Profiles of older Medicare decedents.  J Am Geriatr Soc. 2002;50(6):1108-1112PubMedArticle
Kiely DK, Givens JL, Shaffer ML, Teno JM, Mitchell SL. Hospice use and outcomes in nursing home residents with advanced dementia.  J Am Geriatr Soc. 2010;58(12):2284-2291PubMedArticle
Mitchell SL, Teno JM, Kiely DK,  et al.  The clinical course of advanced dementia.  N Engl J Med. 2009;361(16):1529-1538PubMedArticle
Gozalo P, Teno JM, Mitchell SL,  et al.  End-of-life transitions among nursing home residents with cognitive issues.  N Engl J Med. 2011;365(13):1212-1221PubMedArticle