In this sample of 1,817 older adults who were living in nursing homes at the end of life, we found that lengths of stay for the majority of decedents were brief: less than six months. We also found that decedents’ lengths of stay differed according to a number of demographic, social, and clinical factors and some of these differences were dramatic. Demographic and social indicators often related to having increased access to paid and informal caregiver support include being male, married, and having a higher net worth.10
These indicators revealed significantly shorter nursing home lengths of stay at the end of life. Additionally, those who were diagnosed with a chronic illness often associated with rapid functional decline, such as cancer, had shorter median lengths of stay at the end of life than those diagnosed with an illness generally associated with more progressive functional decline, such as stroke or heart disease.
Brief lengths of stay at the end of life coupled with the variability that exists among subgroups highlights the importance of addressing advance care planning needs with residents and families, as there may be shorter periods of time to address important end-of-life tasks with some residents than with others. There is growing support for the notion that advance care planning conversations, including hospice and palliative care options, ought to occur shortly after admission and be readdressed periodically with nursing home residents and their families.11, 12
Currently, many nursing home residents do not have any documentation of advance directives. In 2004 only 44% of nursing home residents had any advance directive recorded at admission and only 63% of residents had any advance directive orders after 12 months in the nursing home.13
Yet, lengths of stay (and life) were within the window of hospice eligibility for most patients among this sample of decedents at the time of nursing home admission.
While the rates of hospice use in our sample are unknown, hospice care appears to be underutilized in long-term care settings.11, 12, 14
Currently, estimates of the proportion of nursing home decedents in the United States who received hospice or palliative care range from less than 10% to 30% 15, 16
. Research suggests that hospice care improves the quality of life at the end-of-life in long term care settings. A 2002 study by Miller and colleagues found that 51% of dying nursing home residents who were enrolled in hospice (n=2,644) received analgesics for daily pain, compared to 33% of non-hospice residents (n=7,929)17
. Family satisfaction with symptom care has been shown to be superior for long-term care residents enrolled in hospice compared to non-hospice residents.18
Evidence suggests that non-hospice palliative care teams and palliative care education for nursing home staff improves patient care19
. Unlike hospice care, which is bound by criteria related to prognosis and goals of care, non-hospice palliative care may be offered in conjunction with curative treatments for chronically or terminally ill residents despite their expected prognosis, code status, or treatment plan. Unfortunately, while many nursing homes have some affiliation with a hospice, few nursing home providers have received any training in palliative care.11, 14, 20
These findings may have important implications for nursing home care, as it now often focuses on rehabilitation.11, 12
A 1991 survey of North Carolina nursing homes reported 8 percent of patients were in daily specialized rehabilitation.21
By 2006, however, rehabilitation accounted for 86 percent of all Medicare reimbursement days in skilled nursing facilities nationwide22
. Many of these changes are due to financial policy rather than clinical factors.23
Rehabilitation is an important goal for many, but some patients may benefit more from a palliative approach24-26
Though over half of decedents resided in a long-term care setting for less than six months before death, the range in lengths of stay within this study population was large (ranging from less than one month to more than 10 years). Eligibility for the Medicare hospice benefit is prognosis based: patients must have a physician estimated prognosis of less than six months to live. While we do not have data in our study on the expected prognosis of subjects at the time of admission, in general, prognosis for nursing home residents can be difficult to determine.27-29
The Medicare hospice benefit may more appropriately and effectively serve older adults at the end of life if eligibility criteria were redefined by symptom and psychosocial needs, rather than prognosis.
Unlike our study, previous studies have been limited to describing nursing home residents whose physical location of death was the nursing home, excluding those who resided in a nursing home near the end of life but were transferred to the hospital in the hours or days prior to death 2, 30-32
. For these patients, however, the optimal time and place to address palliative needs is likely the nursing home setting where they spend the last weeks or months of life, not the hospital where they spend the final moments prior to death33
Limitations of this study are noted. The HRS enrolls community dwelling older adults and tracks them over time as they age and enter nursing homes. Additionally, the few residents of nursing homes admitted at a younger age would not be captured in this study, biasing our findings toward shorter lengths of stay. We relied on after death interviews with next-of-kin to determine the admission date to the nursing home. In addition to the issue of recall bias, lengths of stays for nursing home residents who were transferred to the hospital due to acute illness and then later readmitted may not be accurately presented in this study. However, subjects’ next-of-kin are unlikely to have counted readmission to the nursing home after hospitalization as a new start date. In this way our data may be superior to administrative data that count only the length of stay for the final admission prior to death. We do not know the reason for admission to the nursing home, and some patients may have been admitted specifically for end-of-life care. We excluded patients admitted to residential hospice facilities, although some residential hospice facilities may have been located within nursing homes. Given the complexities of the study design, we were unable to track time trends in nursing home use in the HRS. The prognoses for patients in our study were not known at the time of admission. Retrospective studies of end-of-life care have been criticized as identifying patients who are dying can be challenging for clinicians;34
thus, studies of the dying differ from studies of decedents.35
However, studies of decedents may offer utility in identifying patterns that add incrementally to our understanding of how to care for patients at the end of life.36
Future prospective studies in this area are needed to further examine trends in nursing home lengths of stay at the end of life over time, and identify additional clinical and social indicators that may be significantly associated, such as functional status, expected prognosis at admission, and the number of hospital readmissions that take place prior to death. Authors of this study are in the process of linking HRS data to Medicare claim data to identify those patients who utilize hospice benefits or acute care services at the end of life. Given that median lengths of stay in a nursing home were less than a year, studies are also needed to examine the possible fiscal implications nursing home lengths of may have for individuals interested in purchasing long term care insurance.
In conclusion, brief nursing home lengths of stay among older adult decedents highlight the importance for health care providers to discuss and address advance care planning needs with patients and families, including palliative and hospice care options, soon after admission to the nursing home.