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11-10-2011 | Article

’Burdensome transitions’ lower quality of end-of-life care

Abstract

Free abstract

MedWire News: Burdensome transitions among nursing home residents with advanced cognitive and functional impairment at the end of life are common and lessen their quality of life (QoL), show study results using US Medicare data.

The researchers defined burdensome transitions as those that occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, and more than one hospitalization in the last 90 days of life.

Transitions such as these "have the potential for fragmentation of care, changes in the management of chronic diseases, duplication of diagnostic workups, and medical errors," explain Joan Teno (Brown University, Providence, Rhode Island, USA) and colleagues in the NEJM.

"Pertinent sources of distress include the trauma of the physical transfer, increased confusion because of unfamiliar settings and providers, inadequate ability to address the patient's special needs (eg, assistance with feeding), and lack of communication regarding goals of care," they add.

The team used data from the Medicare Minimum Data Set from 2000 through 2007 to describe rates of burdensome transition and outcomes that are markers of poor QoL including feeding-tube insertion and hospitalization in an intensive care unit (ICU) in the last month of life.

Of the 474,829 nursing home residents with advanced cognitive impairment who died during the study period, 19.0% had at least one burdensome transition, report the researchers. The majority of residents (73.0%) had a do-not-resuscitate (DNR) order.

The types of burdensome transition experienced by the cohort were full healthcare transitions within the last 3 days of life (11.6%), a lack of continuity in nursing home provider in the last 90 days of life (2.7%), and multiple hospitalizations in the last 90 days of life (8.1%).

During the study period, the rate of burdensome transitions increased from 17.4% in 2000 to 19.6% in 2007.

Patient factors significantly associated with burdensome transitions after adjustment for confounders were Black race (risk ratio [RR]=1.24), male gender (RR=1.20), and a lack of written advance directive, DNR order, or do-not-hospitalize order (RR=1.15, 1.63, 2.14, respectively), observe Teno et al.

Geographic location also affected the likelihood of experiencing a burdensome transition, with nursing home residents in regions with the highest quintile of transitions more likely to have a feeding tube (RR=3.38), to spend time in an ICU in the last 30 days of life (RR=2.10), to have a stage IV decubitus ulcer (RR=2.28), or to be enrolled into a hospice late (RR=1.17), compared with residents in regions with the lowest quintile of burdensome transitions.

Teno and co-workers note that almost 100% of family members say that comfort is the primary goal of care for their relatives with advanced dementia.

However, their results illustrate that "the pattern of transitions among nursing home residents with advanced cognitive impairment is often inconsistent with that goal."

A decline in these transitions will eventually come about through a combination of "improved provider incentives and decision-making that elicits and respects the choices of patients," concludes the research team.

By Sarah Guy