Everyone wants a dignified death - yet few actually experience one. Despite preferring to remain at home, most older adults spend their final days in hospitals, where they often undergo medical care that neither improves survival nor quality of life.
A new study from the University of Pennsylvania School of Nursing's Center for Health Outcomes and Policy Research (CHOPR) describes the quality of end of life care in nearly 500 U.S. hospitals, utilizing nearly 13,000 bedside nurses as informants of quality. The study has been published online first. It will also be in a future issue of the Journal of the American Geriatrics Society.
The majority of nurses (58%) rate their hospital's end of life care unfavorably. The most common quality problem nurses cite (53% of nurses) is that patients often experience painful procedures that are not likely to change their clinical outcome. This finding is consistent with growing trends towards aggressive medical intervention in the final days of life, which is widely recognized as inappropriate for terminally ill individuals.
More than one-third (37.7%) of nurses report being discouraged from discussing alternative care options with patients/families. A similar percentage of nurses say they often disagree with their physician colleagues about end of life care decisions - and feel decisions are not made as a team.
"Even the best hospitals have significant room for improvement when it comes to providing better care for patients at the end of life" says lead-author Karen Lasater, PhD, RN, Assistant Professor of Nursing. "Hospitals are failing to capitalize on an already available cadre of skilled end of life care providers available for every patient in every hospital - registered nurses at the bedside."
The study found that end of life care is best in hospitals characterized by effective nurse-physician teamwork, where authority is devolved to nurses to act in their areas of expertise, where nurses have manageable workloads, and where nurses are highly engaged in hospital decision making.
"For patients and families, making health care decisions at the end of life is stressful. They want to be cared for by a team of providers that elicit and respect their care preferences. They want information about disease progression, symptom management, and the full array of care options. They want to be acknowledged as a whole person - with goals beyond prolonging life. This is at the heart of nurses' work," says Lasater.
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