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: EnglishDying in old age has become the majority dying of the developed world, yet older people are routinely denied palliative care, their dying characterized by failure to facilitate choice and recognize their needs. Social workers in all settings should embrace their contribution to quality end-of-life care for older people.FrenchMourir à un âge avancé est devenu la ‘forme majoritaire de la mort’ dans le monde développé, bien que l’on dénie couramment aux personnes âgées l’accès aux soins palliatifs, leur décès étant socialement caractérisé par l’incapacité à faciliter leurs choix et à reconnaître leurs besoins. Les travailleurs sociaux dans tous les dispositifs devraient apporter leur contribution à la qualité des soins de fin de vie pour les personnes âgées.SpanishMorirse de viejo se ha convertido en la forma mayoritaria de morir en el mundo desarrollado, sin embargo, a los ancianos se les niega sistemáticamente el cuidado paliativo. Sus muertes se caracterizan por el fallo de no ofrecer a los ancianos opciones y reconocer sus necesidades. Los trabajadores sociales de todas partes deben contribuir a la calidad del cuidado al final de la vida de los ancianos.International Social Work 01/2009; 52(6):713-725. · 0.48 Impact Factor
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ABSTRACT: Abstract Background: Advance directives are an important but underutilized resource. Reasons for this underutilization need to be determined. Objective: We investigated factors associated with completion of advance directives among inpatients. Design: We conducted prospective, structured interviews on family structure, health care, disease, and end-of-life experiences. We compared those with completed advance directives and those without. Setting/Subjects: We interviewed 130 inpatients in an urban university hospital. Measurements: We used bivariate analysis and logistic regression to identify characteristics of patients with living wills and health care proxies versus patients without them. Results: Twenty-one percent of patients had a living will and 35% had a health care proxy. Patients with completed living wills were older (p≤0.0046), had more comorbidities (p=0.018), were widowed (p=0.02), and were more often admitted with chronic disease (p=0.009) compared to those without living wills. Patients with health care proxies were older (p<0.001), had religious affiliations (p=0.04), more children (p=0.03), and more often widowed (p≤0.001) than those without health care proxies. Patients were 10.8 times (95% confidence interval [CI] 4.59-25.3), 46.5 times (95% CI 15.1-139.4), and 68.6 times (95% CI 13.0-361.3) more likely to complete a living will when asked by medical staff, legal staff, or family and friends, respectively, than those not asked. Patients with health care proxies were 1.68 times (95% CI 0.81-3.47), 4.34 times (95% CI 1.50-12.6), and 18.0 times (95% CI 2.03-158.8) more likely to have been asked by the same groups. Patients with experience in end-of-life decision-making were 2.54 times more likely to possess a living will (95%CI 1.01-6.42) and 3.53 times more likely to possess a health care proxy (95% CI 1.51-8.25) than those without experiences. Conclusions: Having been asked about advance directives by medical staff, legal staff, or family and friends increases the likelihood that patients will possess an advance directive. Those with prior experience with end-of-life decision-making are more likely to possess an advance directive. Family structure and health care utilization also impacts possession of advance directives.Journal of palliative medicine. 07/2014;
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ABSTRACT: This article reviews the literature on advance directives among U.S. older adults published from 2008 through 2013, with a focus on advance directive prevalence, implications of advance directives on patient care, and impact of interventions to increase advance directive completion. Advance directive completion varies by demographic characteristics and is affected by patient attitudes toward advance directives and end-of-life care. Patients with advance directives are less likely to receive feeding tubes, experience burdensome transitions between nursing homes and hospitals, and die in the hospital. Advance directive completion increases when health care providers ask culturally sensitive questions and educate patients about advance directives, but better documentation and communication of advance directives are needed to ensure adherence to these measures. Despite increasing advance directive completion as patients move from community to nursing homes to hospice, advance directives are often insufficiently detailed and current for health care professionals to be confident they are acting in accordance with what patients would choose for themselves. [Journal of Gerontological Nursing, xx(x), xx-xx.].Journal of Gerontological Nursing 03/2014; · 0.62 Impact Factor