Now is the time to embrace nursing homes as a place of care for dying persons.

293 IN MY EXPERIENCE, requests for funding to improve the quality of end-of-life care in nursing homes are often met with the statement that you have the wrong goal—rather, your priority should be avoiding the use of nursing homes. In fact, how to avoid institutionalization of frail, older persons has been an important research priority. This goal reflects the low regard that many have for nursing homes, and ignores the fact that nursing homes are the final residence for many frail persons dying of chronic, progressive illnesses. Nursing homes are providing this care in the face of substantial challenges such as declining reimbursement, staffing shortages, and high staff turnover. In the United States, as well as other industrialized nations, nursing homes are increasingly becoming the place of care and site of death. In both England and Australia, 1 in 5 persons now dies in a nursing home.1 In the United States, currently, 1 in 4 persons dies in a nursing home, and in 6 U.S. states, the rate is more than 1 in 3.a By 2020, nearly 1 in 2 persons will die in a nursing home.2 Nursing homes in this country now must provide care for persons admitted under a range of circumstances: recently hospitalized persons needing short-term rehabilitation; frail persons, many with cognitive impairments who need custodial and skilled nursing care; and dying, frail, older persons who lack a caregiver or whose caregivers cannot meet their needs for care. Nursing homes are taking on an increasing role in caring for the dying at a time when the U.S. federal government has imposed incentives to discharge patients “quicker and sicker,” and reduce health care costs through a prospective payment system (PPS). Financial pressures have led many nursing homes to file for bankruptcy. Attempts to curtail health care costs are occurring at the same time that important concerns have surfaced about the quality of care for nursing home residents. Such concerns have led to regular state inspections of nursing homes, the results of which are already being posted on the Internet along with information for consumers on how to choose a nursing home.b Since the fall of 2002, 10 quality indicators, including pain management, are now reported for all Medicarecertified U.S. nursing homes. The main focus of these indicators reflects the primary goal of nursing homes as stated in the Omnibus Budget Reconciliation Act of 1987, “to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.”3 The key words, “highest practicable,” reflect that the focus should be on maintaining the highest possible level of functioning in nursing home residents. The highest possible level of functioning has been interpreted such that weight loss and dehydration are seen as evidence of poor quality care. Translating this interpretation into state inspection standards and quality indicators creates goals that can be at odds with quality end-of-life care, which emphasizes patient preferences4 and an acceptance of decline as part of the dying process. One person, for example, may state a preference (through a written advance directive or through their family invoking substituted judgment) to have a feeding tube placed when they reach a stage of advanced dementia, whereas another person may decide, based on concerns with quality of life, that their care should forgo artifi-