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End-of-life care in nursing home settings: Do race or age matter?

Published online by Cambridge University Press:  19 February 2008

Kimberly S. Reynolds ,
Laura C. Hanson ,
Martha Henderson  and
Karen E. Steinhauser
Kimberly S. Reynolds*
Affiliation:
UNC Project, Lilongwe, Malawi School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Laura C. Hanson
Affiliation:
School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Martha Henderson
Affiliation:
School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Karen E. Steinhauser
Affiliation:
Health Services Research and Development Service, Durham VA Medical Center, Durham, North Carolina Department of Medicine, Centre for Palliative Care, Duke University, School of Medicine, Durham, North Carolina
*
Address correspondences and reprint requests to: Kimberly S. Reynolds, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. E-mail: [email protected]
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Abstract

Objective:

One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.

Methods:

We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care—advance care planning and pain management—and on residents' demographic and health status variables. Analyses tested for differences by race and age.

Results:

White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.

Significance of results:

To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.

Keywords

Nursing homesPalliative careAdvance care planningPain managementHealth disparities
Type
Original Articles
Information
Palliative & Supportive Care , Volume 6 , Issue 1 , March 2008 , pp. 21 - 27
Copyright
Copyright © Cambridge University Press 2008

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References

REFERENCES

Allcock, N., McGarry, J., & Elkan, R. (2002). Management of pain in older people within the nursing home: A preliminary study. Health & Social Care in the Community, 10, 464–471.CrossRefGoogle ScholarPubMed
Anderson, K.O., Mendoza, T.R., Valero, V., et al. (2000). Minority cancer patients and their providers: Pain management attitudes and practice. Cancer, 88, 1929–1938.Google Scholar
Baier, R.R., Gifford, D.R., Patry, G., et al. (2004). Ameliorating pain in nursing homes: A collaborative quality-improvement project. Journal of the American Geriatrics Society, 52, 1988–1995.Google Scholar
Berger, J.T. (1998). Culture and ethnicity in clinical care. Archives of Internal Medicine, 158, 2085–2090.Google Scholar
Crawley, L., Payne, R., Bolden, J., et al. (2000). Palliative and end-of-life care in the African American community. JAMA, 284, 2518–2521.CrossRefGoogle ScholarPubMed
Degenholtz, H.B., Arnold, R.A., Meisel, A., & Lave, J.R. (2002). Persistence of racial disparities in advance care plan documents among nursing home residents. Journal of the American Geriatrics Society, 50, 378–381.Google Scholar
Engle, V.F., Fox-Hill, E., & Graney, M.J. (1998). The experience of living-dying in a nursing home: Self-reports of black and white older adults. Journal of the American Geriatrics Society, 46, 1091–1096.Google Scholar
Ferrell, B.A. (1993). The assessment and control of pain in the nursing home. In Improving Care in the Nursing Home: Comprehensive Reviews of Clinical Research, Rubenstein, L.Z. (ed.), pp. 241–250. Thousand Oaks, CA: Sage Publications.Google Scholar
Ferrell, B.A. (1995). Pain evaluation and management in the nursing home. Annals of Internal Medicine, 123, 681–687.Google Scholar
Hanson, L.C., Reynolds, K.S., Henderson, M., et al. (2005). A quality improvement intervention to increase palliative care in nursing homes. Journal of Palliative Medicine, 8, 576–584.CrossRefGoogle ScholarPubMed
Happ, M.B., Capezuti, E., Strumpf, N.E., et al. (2002). Advance care planning and end-of-life care for hospitalized nursing home residents. Journal of the American Geriatrics Society, 50, 829–835.Google Scholar
Hern Jr., H.E., Koenig, B.A., Moore, L.J., et al. (1998). The difference that culture can make in end-of-life decisionmaking. Cambridge Quarterly of Healthcare Ethics, 7, 27–40.Google Scholar
Hopp, F.P. (2000). Preferences for surrogate decision makers, informal communication, and advance directives among community-dwelling elders: Results from a national study. Gerontologist, 40, 449–457.CrossRefGoogle ScholarPubMed
Hopp, F.P. & Duffy, S.A. (2000). Racial variations in end-of-life care. Journal of the American Geriatrics Society, 48, 658–663.Google Scholar
Kagawa Singer, M. & Blackhall, L.J. (2001). Negotiating cross-cultural issues at the end of life: “You got to go where he lives”. JAMA, 286, 2993–3001.Google Scholar
Kiely, D.K., Mitchell, S.L., Marlow, A., Murphy, K.M., & Morris, J.N. (2001). Racial and state differences in the designation of advance directives in nursing home residents. Journal of the American Geriatrics Society, 49, 1346–1352.Google Scholar
Kovach, C.R., Weissman, D.E., Griffie, J., et al. (1999). Assessment and treatment of discomfort for people with late-stage dementia. Journal of Pain & Symptom Management, 18, 412–419.Google Scholar
Lurie, N., Pheley, A.M., Miles, S.H., et al. (1992). Attitudes toward discussing life-sustaining treatments in extended care facility patients. Journal of the American Geriatrics Society, 40, 1205–1208.CrossRefGoogle ScholarPubMed
Mark, D.H., Bahr, J., Duthie, E.H., et al. (1995). Characteristics of residents with do-not-resuscitate orders in nursing homes. Archives of Family Medicine, 4, 463–467.Google Scholar
Miller, S.C. & Mor, V. (2004). The opportunity for collaborative care provision: The presence of nursing home/hospice collaborations in the U.S. Journal of Pain and Symptom Management, 28, 537–547.CrossRefGoogle ScholarPubMed
Mitchell, S.L., Kiely, D.K., & Hamel, M.B. (2004). Dying with advanced dementia in the nursing home. Archives of Internal Medicine, 164, 321–326.Google Scholar
Morrison, R.S., Zayas, L.H., Mulvihill, M., et al. (1998). Barriers to completion of health care proxies: An examination of ethnic differences. Archives of Internal Medicine, 158, 2493–2497.CrossRefGoogle ScholarPubMed
O'Brien, L.A., Grisso, J.A., Maislin, G., et al. (1995). Nursing home residents' preferences for life-sustaining treatments. JAMA, 274, 1775–1779.CrossRefGoogle ScholarPubMed
Oliver, D.P., Porock, D., & Zweig, S. (2005). End-of-life care in US nursing homes: A review of the evidence. Journal of the American Medical Directors Association, 6(Suppl.), S20–S30.Google Scholar
Pallant, J. (2001). SPSS Survival Manual. Buckingham, UK: Open University Press.Google Scholar
Phipps, E., True, G., Harris, D., et al. (2003). Approaching the end of life: Attitudes, preferences, and behaviors of African-American and white patients and their family caregivers. Journal of Clinical Oncology, 21, 549–554.CrossRefGoogle ScholarPubMed
Reynolds, K.S., Henderson, M., Schulman, A., & Hanson, L.C. (2002). Needs of the dying in nursing homes. Journal of Palliative Medicine, 5, 895–901.Google Scholar
Singer, P.A., Martin, D.K., & Kelner, M. (1999). Quality end-of-life care: Patients' perspectives. JAMA, 281, 163–168.CrossRefGoogle ScholarPubMed
Stein, W.M. (2001). Pain in the nursing home. Clinics in Geriatric Medicine, 17, 575–594.CrossRefGoogle ScholarPubMed
Steinhauser, K.E., Christakis, N.A., Clipp, E.C., et al. (2000). Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA, 284, 2476–2482.CrossRefGoogle ScholarPubMed
Teno, J.M. (2004). Do-not-resuscitate orders and hospitalization of nursing home residents: Trumping, neglect, or shared decision-making at the eleventh hour. Journal of the American Geriatrics Society, 52, 159–160.Google Scholar
Teno, J.M., Weitzen, S., Wetle, T., et al. (2001). Persistent pain in nursing home residents. JAMA, 285, 2081.CrossRefGoogle ScholarPubMed
Terry, M. & Zweig, S. (1994). Prevalence of advance directives and do-not-resuscitate orders in community nursing facilities. Archives of Family Medicine, 3, 141–145.CrossRefGoogle ScholarPubMed
Won, A., Lapane, K., Gambassi, G., et al. (1999). Correlates and management of nonmalignant pain in the nursing home. Journal of the American Geriatrics Society, 47, 936–942.Google Scholar