End-of-life care in nursing home settings: do race or age matter?
ABSTRACT 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.
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.
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.
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.
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ABSTRACT: This study, drawing on a nationally representative sample of community-dwelling adults aged 70 and older from the second wave of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, addresses the need for greater information on advance care planning among older adults. Older persons expect to draw on a diverse array of persons to make health care decisions for them when they are unable to do so, including spouses, when available, as well as younger generation members such as children and grandchildren. Completion of advance directives such as living wills and durable powers of attorney for health care was more common among White respondents than among African American respondents, and among high school- and college-educated respondents compared with those with less than a high school education. The results suggest the need to develop interventions aimed at strengthening knowledge and understanding of advance directives, particularly for African Americans and persons with lower levels of educational attainment. They further suggest the need for more research on the factors related to informal communication between older adults and their family members on issues related to advance care planning.The Gerontologist 09/2000; 40(4):449-57. · 2.48 Impact Factor
Article: Pain in the nursing home.[show abstract] [hide abstract]
ABSTRACT: The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.Clinics in Geriatric Medicine 09/2001; 17(3):575-94, viii. · 3.14 Impact Factor
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ABSTRACT: To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population. A retrospective cohort study. Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH). Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH. Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM). The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3). Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.Journal of the American Geriatrics Society 10/2001; 49(10):1346-52. · 3.98 Impact Factor