Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice invol vement in nursing home care by comparing the survival and needs for palliat ive care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patien ts age 65 and older were identified. Of these, 167 lived in nursing homes a nd 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survi val. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable po wer of attorney for health care (22% vs 10%; P < .001) than were those livi ng in the community. Nursing home residents also had different admitting di agnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home resid ents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .00 1), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home resi dents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorte r survival (median 11 vs 19 days; log rank test of survivor functions P < . 001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming in eligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliat ive care in a substantial proportion of nursing home residents who are refe rred to hospice, although nursing home residents may have fewer identifiabl e needs for care than do community-dwelling older people. However, the find ing that nursing home residents' survival is shorter may be of concern to h ospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.