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End Of Life In A Skilled Nursing Facility

Although most people say they would prefer to die at home, approximately 56 percent die in a hospital and roughly, 22 percent of all U.S. deaths occur in skilled nursing facilities. According to a study conducted by Brown Medical School researchers and published by AARP, the 1 in 4 adult Americans who die in a skilled nursing facility are not always receiving the appropriate care such as pain medication, emotional support and hospice care. In the report, experts offered several recommendations to improve end of life care in skilled nursing facilities. One of the most critical: Improve government reimbursement rates.

“Listening to families’ compelling stories of end of life care, it is clear that nursing homes need more staff and better training for that staff,” said Terrie Wetle, Associate Dean of medicine for public health and public policy and professor of community health at Brown Medical School. “Workers also need to be better paid,” Wetle said. “Even at the best facilities, aides are frequently offered wages that are about what they’d make working at McDonald’s.” But many homes simply don’t have the funds. Another fundamental finding: Appropriate care often isn’t provided because staffers simply don’t recognize that a patient is dying.

Researchers noted that symptoms of terminal illness are often difficult to identify and illness trajectories hard to predict, resulting in additional caregiver burdens, late decisions about hospice care and unnecessary transfers to other skilled nursing facilities. The team also found that dying residents were subjected to unneeded tests or treatments – for example, a comatose resident was restrained in a wheelchair and put in whirlpool bath. The team heard other consistent themes: Doctors that were “missing in action”; aides were overworked and under trained; care was task focused rather than person centered; hospice referrals were made too late or not at all; and, due to a lack of trust, family members found it necessary to become vigilant advocates for their spouses, parents or grandparents.

My daddy by *nicolehinrichs on deviantART

In the 1900’s people often died at home surrounded by family. Physicians routinely comforted the dying and their families. In the past century, medical and public health advances have almost doubled the average life expectancy, from less than 50 years to nearly 80. People who die in old age tend to experience a long period of functional decline before death, and thus require intensive caregiving and well coordinated skilled nursing care. As medical advances have allowed us to delay death, our society has moved death out of the home and into institutions. The United States has become so caught up in the ability to cure disease that our healthcare system forgets that death is inevitable. In an attempt to remember death and reduce costly inpatient hospital stays at the end of life, Medicare established a hospice benefit in 1983.

Hospice was seen as an alternative for use when life prolonging options had been exhausted. The Medicare hospice benefit is available only to patients whose doctors are willing to certify they have a life expectancy of 6 months or less, who agree to receive only palliative care and who have a full time primary caregiver or reside in any type of assisted living facility. Unfortunately, too few patients receive adequate end of life palliative care. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments documented the type of care dying patients in teaching hospitals preferred, and how closely their wishes were followed. The investigators found that patients’ wishes were frequently not followed, and that pain was common. Half the patients able to communicate in the last 3 days of life said they were in severe pain. These findings demonstrate the need for the health system to pursue a higher standard for end of life care in any setting.

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About The Author: Gloria Ha’o Schneider is an expert in senior citizen and baby boomer issues. Her topics revolve around Senior Living and Healthcare to provide the latest information to this demographic as well as their families and loved ones.

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