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Palliative Care Program


Improving End-of-Life Care by Partnering Nursing Homes with Palliative Care Specialists

One in four Americans die in nursing homes, which is projected to increase to 50% by 20401. Moreover, within 30 days of their nursing home admission, one in five residents experiences a "terminal hospitalization,” that is, they die during re-hospitalization2. Even though deaths and terminal hospitalizations are daily occurrences in nursing homes, nursing home nurses report inadequate training in end of life symptom management. Furthermore, both nurses and physicians report insufficient time to address end of life treatment preferences with nursing home residents3. Because nursing home staff have inadequate training in eliciting end-of-life treatment preferences, they tend to oversimplify these discussions by limiting their inquiries to the resident’s preferences regarding cardiopulmonary resuscitation, which is not adequate for end-of-life decision-making in most clinical situations4. Palliative care specialists are nurses and physicians trained to assist patients and families articulate end-of-life care preferences and manage pain and non-pain symptoms. The overall goal of this research is to improve the quality of end-of-life care in nursing homes by partnering nursing homes with palliative care specialists who will perform comprehensive advance care planning and provide treatment of pain and non-pain symptoms for nursing home residents at the end of life.

What is MAPP?

MAPP is an acronym for Making Advance Planning a Priority. This is a collaborative EOL care model for NHs, based on a partnership between NHs and palliative care specialists. NH staff will use a practical instrument to target residents with a high mortality risk for consultation by a palliative care specialist. The specialist will elicit care goals using a standardized, NH-specific EOL care planning tool; communicate EOL preferences to the physician and NH staff; recommend care plan and physician order changes if symptom management is inadequate; and assist nurses with EOL care.

The 2004 NIH Consensus Conference on End of Life Care recommended that new models of EOL care for Medicare beneficiaries be developed and evaluated to overcome limitations of the current Medicare hospice benefit5. Hospice enrollment in NHs is constrained by prognostic criteria and reimbursement specifications whereas the involvement of palliative care specialists is not, allowing for earlier intervention6-8. The MAPP model therefore incorporates palliative care, not hospice services.

  1. Brock D, Foley DJ. Demography and epidemiology of dying in the U.S. with emphasis on deaths of older persons. Hosp J 1998; 13:49-60.
  2. Levy CR, Fish R, Kramer A. Site of death in the hospital versus nursing home of Medicare skilled nursing facility residents admitted under Medicare's Part A benefit. J Am Geriatric Soc 2004; 52:1247-1254.
  3. Keay T, Alexander C, McNally K, Crusse E, Eger E. Nursing Home Physician Educational Intervention Improves End-of-Life Outcomes. J Palliat Med 2003; 6:205-213.
  4. Beach MC, Morrison SR. The effect of do-not-resuscitate orders on physician decision-making. Journal of the American Geriatrics Society 2002; 50:2057-2061.
  5. Heitkemper MM, Bruner DW, Johnson JC, and et al. National Institutes of Health State-of-the-Science Conference Statement: Improving End-of-Life Care. 1-21. 12-8-2004. National Institutes of Health.
  6. Parker-Oliver D, Bickel D. Nursing home experience with hospice. J Am Med Dir Assoc 2002; 3:46-50.
  7. Somogyi-Zalud E. Palliative care--a service to improve the dying experience in hospitals and nursing homes. Hawaii Med J 2002; 61:6-9.
  8. Meier DE, Morrison RS. Old age and care near the end of life. Generations 1999; 23:6-11.