End-of-Life Care in LTC Settings

To the Editor,

I am responding to an article, “End-of-Life Nursing Home Care: Resource Allocation and Ethics.”¹ The section of this article relating to hospice in long-term care (LTC) really got my attention. I have had many experiences with hospice in the LTC setting for the past five years. I have not seen the benefit of hospice in this setting. My experience has been that LTC staff begins the admission process and completes it. We communicate with the primary physician for order clarification, do the initial assessments, pain management, complete all bathing, grooming, feeding, and other activities of daily living without the assistance of hospice. Hospice bills for all care, and the LTC facility can only bill for room and board. I don’t see the logic in this process. Some say that hospice is needed for the grieving process for the families, but I watch our social service personnel playing this role. I don’t think that hospice and LTC are a good mix. Long-term care facilities are faced with palliative care orders everyday and do very well with them. I know that this may be an individual experience, but I feel like hospice is for the home. Many times, the orders that we get from hospice conflict with the policies in the facility, and they don’t seem to understand that we have certain regulations to follow. I feel that the last days of individuals should be spent in the way that they choose. If it is in the nursing home, then let the nursing home handle the palliative care and keep hospice in the home.

Hope Joiner,
RN Crofton, KY

Reference
1. Nusbaum NJ. End-of-life nursing home care: Resource allocation and ethics. Annals of Long-Term Care: Clinical Care and Aging 2007;15(5):23-26. ____________________________________________________________________

Response from Dr. Nusbaum:

The relative strength of the several mechanisms to deliver end-of-life care is likely to differ from one community to another. It is certainly desirable to have a strong nursing home end-of-life program such as you describe. I suspect, however, that some other communities may well have a very different mix of available long-term care healthcare resources for end-of-life care than you report in your setting, and so they may well find hospice to be a valuable component of end-of-life care in their setting. I think we are in agreement that the fundamental issue is providing high-quality care at the end of life, and that this is more important than the specific mechanisms by which it is delivered.

Neil J. Nusbaum, JD, MD
University of Illinois College of Medicine at Rockford