RESUMO
Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.
Assuntos
Cuidados Paliativos na Terminalidade da Vida/organização & administração , Assistência de Longa Duração/organização & administração , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Ética Médica , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Medicare , Avaliação das Necessidades , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Estados UnidosRESUMO
Nursing facilities (NF) are important sites for the care of dying patients. Curricula likely to improve end-of-life care are needed for NF physicians. To this end, a model medical school palliative care curriculum was modified for experienced NF physicians. Adult learning techniques were emphasized, as well as interactions likely to change physician behavior. Inclusion of the opinion leader, audit with feedback, use of consensus guidelines, and other techniques for changing physician behavior were included. Written materials to supplement the course were identified. This new program was pilot tested and improved. An initial audit of physician practices and survey of the NF staff, a half-day adult educational session, and follow-up with the NF medical director is suggested. This intervention should be tested to determine if it improves patient end-of-life care outcomes in this setting.
RESUMO
Hospice care is being used more frequently to provide skills and services that are not otherwise available in nursing homes. For eligible terminally ill patients, the Medicare Hospice Benefit supplies an interdisciplinary team with skills in pain management, symptom control and bereavement assistance. The Medicare Hospice Benefit also covers the cost of durable medical equipment and drugs, except for a nominal drug copayment fee. The services of the hospice team supplement the usual nursing home care at a time when staff, family members and the patient are facing the increased and urgent needs associated with the dying process. The Medicare Hospice Benefit can make it much easier for physicians and nursing home staff to provide comprehensive palliative care for terminally ill patients.
Assuntos
Cuidados Paliativos na Terminalidade da Vida , Casas de Saúde/organização & administração , Instituição de Longa Permanência para Idosos/organização & administração , Humanos , Medicare , Educação de Pacientes como Assunto , Estados UnidosRESUMO
Although approximately one of five people in the United States die in nursing homes (NHs), little has been written about their quality of dying, including the quality of terminal medical care. The purpose of this study is to review actual medical practices in NHs to suggest factors important for delivering good quality terminal care. Four NHs were surveyed for management of residents who died in 1992. A convenience sample of charts of newly admitted and longer term residents were abstracted for demographic variables, death, diagnostic categories, and various laboratory and other parameters. Charts of those residents who died were further reviewed using indicators of quality medical care, such as presence of advance directives, control of pain, and control of dyspnea, based upon recent published clinical practice guidelines for terminal care in NHs. Three hundred and seventy-one charts were abstracted. Forty-one charts documented the resident's death. We found that NHs without regulatory difficulties usually had expected deaths that were managed approximately as measured by terminal medical care quality indicators. NHs with a history of regulatory difficulties had a higher prevalence of residents who died suddenly and unexpectedly, often with problems in the quality of care as measured by the same indicators. There was a correspondence between physician certification, antemortem diagnosis of terminal illness, and appropriate terminal care. We conclude that physicians are able to recognize impending death and redirect the medical care of dying NH residents toward goals of terminal care management. This is more likely to occur in a NH environment that places greater emphasis upon total quality management. We suggest that another indicator in providing good NH terminal care is the physician's performance in predicting a short life expectancy.
Assuntos
Casas de Saúde/normas , Médicos/normas , Qualidade da Assistência à Saúde , Assistência Terminal/normas , Idoso , Idoso de 80 Anos ou mais , Baltimore , Feminino , Humanos , Masculino , Auditoria Médica , Guias de Prática Clínica como AssuntoAssuntos
Pesquisa Empírica , Ética Médica , Consentimento Livre e Esclarecido , Pessoas Mentalmente Doentes , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Esquizofrenia/tratamento farmacológico , Suspensão de Tratamento , Protocolos Clínicos , Revelação , Políticas Editoriais , Comitês de Ética em Pesquisa , Humanos , Competência Mental , Seleção de Pacientes , Recidiva , Projetos de Pesquisa , Sujeitos da Pesquisa , Medição de Risco , Responsabilidade Social , Resultado do TratamentoRESUMO
PURPOSE: To identify medical care indicators for nursing home terminal care. DATA SOURCES: Studies examining care of terminally ill patients were identified using computer, bibliography, and expert searches; input from nursing home medical directors in Maryland; and input from expert geriatricians. STUDY SELECTION: More than 900 articles, books, and abstracts from meetings covering medical care for terminally ill patients were reviewed. Information from more than 100 publications is included. DATA EXTRACTION: Indicators of medical care for terminally ill patients, which can be used to quantify performance with respect to standards, guidelines, and options, were identified initially through review of the literature. DATA SYNTHESIS: Indicators were refined by input from medical directors of Maryland long-term care facilities and subsequent review by expert geriatricians. CONCLUSIONS: Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also described.
Assuntos
Casas de Saúde/normas , Assistência Terminal/normas , Gestão da Qualidade Total , Serviços de Assistência Domiciliar , Humanos , Autonomia Pessoal , Papel do Médico , Estados UnidosAssuntos
Aborto Eugênico , Eticistas , Comitês de Ética Clínica , Comissão de Ética , Terapia Familiar , Cuidados para Prolongar a Vida , Papel Profissional , Assistência Terminal , Adulto , Idoso , Encefalopatias , Consultoria Ética , Feminino , Humanos , Recém-Nascido , Masculino , Equipe de Assistência ao Paciente , Gravidez , GestantesRESUMO
This article identifies key areas of physician performance in nursing homes (NHs) cited by state regulators. Six faculty members of the University of Maryland Department of Family Medicine reviewed medical care in ten Maryland NHs, which constituted 6.7% of Maryland's Comprehensive-level beds, with a sample of 547 charts and 81 physicians. The reviewers recorded the absence of expected minimum standards of performance in patient care. Nine of the NHs had been cited and one was anticipating an audit by state regulators. Citation by regulators corresponded with inadequate documentation of patient history and physical examinations, especially of neurologic conditions; with inadequate health care maintenance; with mismanagement of laboratory findings such as bacteriuria; and with lack of medical administrative leadership and quality management. These key areas of physician performance should be regularly assessed or systematically changed in all NHs to maintain at least minimum standards of care.
Assuntos
Assistência de Longa Duração/normas , Auditoria Médica , Casas de Saúde/normas , Qualidade da Assistência à Saúde , Controle de Formulários e Registros , Maryland , Garantia da Qualidade dos Cuidados de SaúdeRESUMO
The Second Opinion staff invited a number of its readers who are physicians to respond to our recent Case Stories section on medical noncompliance, which included a case story by Kevin Coleman and commentary and overview by Arthur W. Frank (Second Opinion 17, no. 3 [January 1992]). Our thanks to those who shared their reflections, a number of which have been excerpted here.