Palliative care: Nursing home
- Gary S Winzelberg, MD, MPH
Gary S Winzelberg, MD, MPH
- Associate Professor, Division of Geriatric Medicine
- University of North Carolina
- Laura C Hanson, MD, MPH
Laura C Hanson, MD, MPH
- Professor of Medicine, Division of Geriatric Medicine
- University of North Carolina-Chapel Hill
- Section Editors
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
- Maria J Silveira, MD, MA, MPH
Maria J Silveira, MD, MA, MPH
- Section Editor — Special Sites of Care and Allied Health Professions
- Clinician Scientist
- Ann Arbor VAMC
- Associate Professor of Internal Medicine
- University of Michigan
- Christine Ritchie, MD, MSPH
Christine Ritchie, MD, MSPH
- Section Editor — Special Sites of Care and Allied Health Professions
- Professor of Medicine
- Harris Fishbon Distinguished Professor for Clinical Translational Research in Aging
- University of California - San Francisco
Approximately 1.5 million people live in nursing homes and one million reside in assisted living facilities in the United States alone. In addition, a review of 10 economically developed countries including the United States, United Kingdom, and Japan estimated that between 2 and 5 percent of older adults resided in nursing homes . On average, nursing home residents stay in a long-term facility for more than two years . Approximately 25 percent of Americans die in nursing homes, and approximately one-half of these patients die within six months of placement .
Caring for these individuals presents many medical and health system challenges. Most long-term care residents are over age 65 and/or have multiple chronic health conditions affecting their cognitive and physical functioning. While some individuals in nursing homes return home after receiving therapy services, most will remain in a long-term care facility until their deaths.
This topic discusses the palliative care needs of individuals in long-term care settings and initiatives to improve nursing homes' palliative and end of life care services. While data specific to assisted living will be included, virtually all studies and programs have been conducted in nursing homes and this topic will therefore be most relevant to the nursing home population.
Other issues related to both palliative care and the general care of patients in nursing homes are discussed separately. (See "Medical care in skilled nursing facilities (SNFs) in the United States" and "Principles of infection control in long-term care facilities" and "Overview of geriatric rehabilitation: Program components and settings for rehabilitation" and "Management of neuropsychiatric symptoms of dementia" and "Managing multiple comorbidities" and "Benefits, services, and models of subspecialty palliative care" and "Palliative care of patients with advanced dementia".)
SCOPE OF THE PROBLEM
There is a growing appreciation of long-term care residents' needs for palliative care services, especially for those with advanced, incurable, and/or chronic illnesses. These needs include symptom management, care of the dying resident, support for family caregivers, and assistance with decision making regarding diagnostic evaluations and plans if an acute illness were to happen (ie, wishes regarding transfer to an acute care facility).
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- SCOPE OF THE PROBLEM
- PATIENT CHARACTERISTICS, CARE NEEDS, AND CLINICAL COURSE
- Dementia as a primary problem in nursing home residents
- IMPORTANCE OF ESTIMATING PROGNOSIS
- LONGITUDINAL INTAKE OF THE NURSING HOME PATIENT
- New nursing home patients
- Established nursing home patients
- ISSUES IN THE CARE OF THE NURSING HOME PATIENT
- Specific symptoms
- - Pain
- Assessing pain in patients with impaired cognitive function
- - Nonpain symptoms
- DECISION MAKING
- Goals of care communication
- Decisions regarding nutrition and hydration
- - Role of artificial nutrition and hydration
- - Approaching discussions about artificial intake
- Caring for infectious complications
- INITIATIVES TO IMPROVE PALLIATIVE CARE IN LONG-TERM CARE SETTINGS
- SUMMARY AND RECOMMENDATIONS