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.
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