A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.
Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.
“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.
A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).