Hospice use and outcomes in nursing home residents with advanced dementia

Abstract

Objectives: To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life.

Design: Prospective cohort study.

Setting: Twenty-two Boston-area NHs.

Participants: Three hundred twenty-three NH residents with advanced dementia and their HCPs.

Measurements: Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care.

Results: Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57-6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37-7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life.

Conclusion: A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.

Figure 1

Percent of health care proxies perceiving unmet needs in four domains of care for nursing home (NH) residents (N=137) with advanced dementia during the last 7 days of life including: 1) communication with NH providers, 2) information received by NH providers, 3) emotional support provided to the HCPs, and 4) help with basic care provided to the resident. Blue columns represent residents who received hospice care while dying (N=41) and the red columns represent residents who did not receive hospice care while dying (N=96). (No residents who received hospice care had an unmet need with help for their basic care.) The last set of columns presents the proportion of residents who experienced an unmet need in at least one of the four domains. Odds ratios (95% confidence intervals) are presented to estimate the relative protective effect of hospice services on unmet needs.