Quality End-of-Life Care in Nursing Homes

• The influence on palliative care of communication, leadership, and teamwork. [ Time Frame: Nursing home staff: at beginning and end of study; family members: following the death of nursing home resident ] [ Designated as safety issue: No ]
  

• Associations among structure (staffing), non-clinical (communication, leadership, teamwork) and clinical (palliative care) care processes and quality of end-of-life care. [ Time Frame: Nursing home staff: at beginning and end of study; family members: following the death of nursing home resident ] [ Designated as safety issue: No ]
  
• Unruh and Wan's expanded structure, process, and outcomes model in the context of nursing home palliative care. [ Time Frame: Nursing home staff: at beginning and end of study; family members: following the death of nursing home resident ] [ Designated as safety issue: No ]
  

As the American population ages, nursing homes are rapidly becoming a dominant site for death. Currently, 25% of all deaths occur in nursing homes and 35% of all elders over the age of 85 die in nursing homes. By 2020, 40% of those over 65 will die in nursing homes. Nursing home residents die in pain with undue psychosocial suffering. For all permanently placed residents, death is inevitable. Nonetheless, how residents die, is not.

There have been long standing concerns about the quality of care and quality of life in nursing homes. Although there is some evidence that the quality of care for nursing home residents has improved, serious problems continue in areas that potentially affect end-of-life such as dehydration, pressure ulcers, and pain. Efforts to improve care have rarely considered the dynamic nature of nursing home structure and process factors, such as staffing levels, leadership of the director of nursing, or communication and teamwork among staff that facilitate or impede the organization's ability to improve care processes. Findings from our preliminary studies in nursing homes indicate that organizational structure and process factors make a difference in end-of-life care for residents and their family members. More specifically, staff education, staffing levels, leadership of the DON and administrator, teamwork and communication among direct care staff, and incorporating palliative care clinical practices into day-to-day care had a profound impact on outcomes such as the honoring of end-of-life preferences, symptom management, and satisfaction with care. A more generalizable understanding of key structure and process factors and their relationship to resident care and outcomes at the end-of-life will provide a foundation for future intervention studies aimed at improving care.