This document provides an overview of a conference on integrating palliative care into nursing homes. It describes the growing elderly population in nursing homes, many of whom have advanced dementia or other serious illnesses. The document outlines the roles and responsibilities of different nursing home staff in delivering palliative care, including assessing symptoms, facilitating goals of care discussions, and offering bereavement support. It recommends strategies for preparing staff, such as educating them about palliative care principles and conducting skills assessments. The document also reviews ways to evaluate the quality of palliative care through structure, process and outcome measures.

1. Jewish Home Lifecare 11th Annual Geriatric Palliative Care
Conference, November 12, 2013
Mary Ersek, PhD, RN, FAAN
Philadelphia VAMC
University of Pennsylvania School of Nursing
ersekm@nursing.upenn.edu

2. Describe the growing need for integrating
palliative care into nursing homes.
Describe the role of nursing in palliative care.
Describe strategies to prepare nursing staff
for delivering palliative care and in leading
palliative care practices.

3. Between 1.5–1.8 million people live in US
nursing homes (NHs) Kaye et al, Health Affairs, 2010
By 2050, more than 3 million people are
expected to spend time in a NH Kaye et al, 2010
28% of persons ≥ 65 years died in a NH in 2007
CDC NCHS, 2010
Nearly 70% of persons with advanced dementia
die in a NH Mitchell et al, JAGS, 2005

4. Over half are totally dependent or need extensive
assistance with bathing, dressing, toileting, and
transferring
67% of nursing home residents are female
64.8% have moderate to severe cognitive impairment
78.9% are non-Hispanic White
15.3% reported moderate to severe pain (last 5 days)
35.6% incontinent of bowel and/or bladder
25.5% received antipsychotic medication (last 7 days)
Average length of stay ≈ 2 years
Nursing Home Data Compendium, 2012 Edition

6. Nursing Assistants
Licensed nursing staff (RNs and LPNs)
Medication and Treatment nurses
Unit manager
Care manager
MDS Coordinator
Staff educator
Quality Improvement Director
Assistant Director of Nursing
Director of Nursing/Clinical Services
Nurse Practitioners

7. Identifying and documenting goals of care
Facilitating completion of advance directives
Assessing and managing symptoms
Facilitating life closure
Offer grief and bereavement support
Decreasing burdensome transitions
Maximizing human dignity

8. 1. Hospice
2. External palliative care teams
3. Internal palliative care teams/units

9. Education
Knowledge
Attitudes
Policies: development and implementation
Teams
Role modeling
Quality improvement – monitoring progress

10. License nursing staff, certified nursing
assistants, activities director, etc.
Self-assessment
Supervisor assessment
Knowledge assessment

12. Internal Teams
Principles of palliative care
Hospice 101
Pain and symptom
management
Communication with residents
and families
Goals of care/Advance
directives/POLST
Ethical issues
Cultural and spiritual issues
Loss, grief and bereavement
Care for imminently dying
Quality improvement
External Teams (including hospice)
Nursing home history
Nursing home culture
Work teams and organization
Staff as family
Central role of CNAs
Family involvement
Nursing home regulations
Nursing home trends
Dementia care
Geriatrics
Respect for NH work and staff

13. EOL/Palliative Educational Resource Center
(EPERC), www.eperc.mcw.edu/EPERC
Advancing Excellence,
www.nhqualitycampaign.org
Geriatric Pain, www.geriatricpain.org
Prepare for Your Care,
www.prepareforyourcare.org

15. “No complaints of pain”
“That’s the way she always is…”
“Of course she’s in pain…she’s 92, what do you
expect?”

16. Policies and procedures: Symptom assessment
& management
Policies and procedures: Advanced directives,
assessing capacity
Policies and procedures: Management of acute
conditions

17. Demonstrates knowledge of pain assessment
techniques
Re-evaluates pain following pain medications and
nondrug pain intervention
Advocates for residents experiencing pain
Role models best practices for pain assessment
Consistently observes and reports to the nurse
residents’ reports of pain and/or pain-related
behaviors
Solicits all team members’ evaluations of
residents’ pain.

18. Quality improvement team
Training team
Pain management team
Goals of care team
Transitions team

19. Ask about a residents’
comfort level
Report a resident’s
concerns to the nurse
Advocate for a resident
Communicate respectfully
Keep families informed

20. RN/LPN
Nurse
practitioner
Nursing
assistants
DON/Admin
RESIDENTS
Physician
Non-nursing
staff
Family

21. Structure
Process
Outcome

22. Structure:
Policies - symptom assessment & management, advance
directives
Protocols for managing acute conditions to avoid
hospitalizations
Process:
Documentation of pain management plan and f/u
Documentation of AD
Outcomes:
Resident symptoms (chart/MDS)
Care matches preferences
Bereaved Family Perceptions of Care at EOL
Hospitalizations, ER visits
Staff satisfaction, staff turnover

23. MDS:
Symptoms: Pain, dyspnea; Depressive symptoms (PHQ-9)
Feeding tubes
Hospice
Quality indicators
Percent of Residents who Self-Report Moderate to Severe
Pain (Short and Long Stay)
Percent of Residents Who Have Depressive Symptoms (Long
Stay)
F-tag 309 – Pain and End-of-life Care