Access to palliative care and hospice in nursing homes

Nursing homes are the site of death for many elderly patients with incurabl e chronic illness, yet dying nursing home residents have limited access to palliative care and hospice. The probability that a nursing home will be th e site of death increased from 18.7% in 1986 to 20.0% by 1993. Dying reside nts experience high rates of untreated pain and other symptoms. They and th eir family members are isolated from social and spiritual support. Hospice improves end-of-life care for dying nursing home residents by improving pai n control, reducing hospitalization, and reducing use of tube feeding, but it is rarely used. For example, in 1997 only 13% of hospice enrollees were in nursing homes while 87% were in private homes, and 70% of nursing homes had no hospice patients. Hospice use varies by region, and rates of use are associated with nursing home administrators' attitudes toward hospice and contractual obligations. Current health policy discourages use of palliativ e care and hospice for dying nursing home residents. Quality standards and reimbursement rules provide incentives for restorative care and technologic ally intensive treatments rather than labor-intensive palliative care, Reim bursement incentives, contractual requirements, and concerns about health c are fraud also limit its use. Changes in health policy, quality standards, and reimbursement incentives are essential to improve access to palliative care and hospice for dying nursing home residents.