Barriers to the Implementation of Palliative Care in the Nursing Home

Although residents of nursing homes (NH) could greatly benefit from palliative care, most NHs do not have a clear understanding of how to incorporate the philosophy of palliative care into the mainstream of medical care. This lack of process can lead to barriers between members of the interdisciplinary team at the NH. Specifically, barriers can result from poor communication, lack of coordination of care, inadequate pain and symptom control, and differences in the perceived value of research in the NH setting. The National Consensus Project for Quality Palliative Care lists core outcomes for palliative care. 1 Among these core outcomes are high-quality communication, coordination of care, and control of pain and symptoms. Palliative care is care given by an interdisciplinary team that focuses on the prevention and relief of suffering for patients and their families when the patient has a life-limiting condition. 2 The interdisciplinary team usually consists of a physician, nurse, chaplain, and social worker, but can also include volunteers, pharmacists, nursing assistants, nutritionists, and therapists. The NH is an ideal location for the practice of palliative care because an interdisciplinary team already exists and numerous residents at the NH have lifelimiting conditions. MAGNITUDE OF THE PROBLEM Currently, 66% of residents remain in nursing facilities to die rather than being transferred to a hospital for their final days. 3 Now that more people are dying in the NH coupled with the growing percentage of people who spend or will spend time in a NH, it becomes imperative that the principles of palliative medicine be practiced by all health care professionals who work at the NH. When we tried to implement palliative care in a NH, we encountered barriers because of poor communication, lack of coordination of care, inadequate pain and symptom control, and the perceived insignificant value of palliative care research by members of the interdisciplinary team at the NH. The following cases illustrate the magnitude of the problem with implementing effective palliative care in the NH. BARRIERS SURROUNDING COMMUNICATION ● A 90-year-old white female with end-stage Alzheimer’s dementia: The NH medical director discussed goals of care with the patient’s health care surrogate (HCS). The HCS stated that the goals were comfort-only and the medical director explained the do not hospitalize (DNH) order. The HCS wanted DNH for the patient; therefore, the physician wrote this order. The NH director of nursing questioned the DNH order. She thought it meant the patient would receive no treatment. She also did not think the patient had a terminal diagnosis. The physician should have communicated and explained the orders with the nursing staff when the orders were written. The physician also should have written “End-stage Alzheimer’s dementia” along with the DNH order, which would have communicated to the staff the natural progression of Alzheimer’s dementia. The barriers in this case stem from a lack of communication about the natural progression of Alzheimer’s dementia and the meaning of DNH.