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Nursing homes falling behind with end-of-life directives

January 17, 2017

COLUMBIA, Mo. - Popular medical dramas such as Grey's Anatomy and Chicago Med often depict the tensions that can arise while making end-of-life medical decisions without "advance directives" on file. Advance directives, or living wills, are the legal documents individuals use to communicate their treatment preferences when faced with serious injuries or illnesses. Following a new study, Colleen Galambos, professor in the University of Missouri School of Social Work, says that more attention to how advance directives are used in nursing homes may reduce unnecessary care and save health care costs, all while respecting residents' wishes.

"In the nursing home setting, some providers use aggressive end-of-life care, even if it is not in a person's best interest or against a resident's wishes," Galambos said. "Evidence suggests that advance directives improve the dying experience for nursing home residents and decrease the cost of end-of-life care while honoring residents' expressed wishes about health care. However, at the national level only 65-70 percent of nursing home residents have advance directives; that number is significantly less here in Missouri."

Galambos and her team analyzed more than 1,800 medical records from St. Louis area nursing homes. Fifty percent of the records contained an advance directive; however, in many cases the forms were difficult to find in the charts, due to inconsistent record keeping. Galambos recommends that providers include a designated section in medical files for advance directives and that they reinforce with staff the importance of checking advance directives.

Galambos further suggests that parents and adult children begin discussions about their wishes for health care, including end-of-life care, as soon as possible, and that the forms be updated on a regular basis as health needs and philosophies of life can change. She says that no family member wants to be in a position to have to guess about what type of care their loved ones want when they are no longer able to communicate their wishes.

"There is no reason for adults not to have an advance directive and most nursing home residents should have an advance directive on file to ensure that they receive the type of end-of-life care they desire," Galambos said. "People can enact an advance directive at age 18, which is a good time to start thinking about what their wishes would be during an emergency."

"Analysis of advance directive documentation to support palliative care activities in nursing homes," recently was published in Health and Social Work, a journal of the National Association of Social Workers. Co-authors for the study were Marilyn Rantz, Curators' Professor of Nursing; Gregory Petroski, biostatistician with the Office of Medical Research; and Julie Starr, nurse practitioner with MU Health.

Galambos recently was selected as a National Association of Social Workers (NASW) Social Work Pioneer of the Year for her contributions to the social work profession. Galambos is the director of the graduate certificate in Gerontological Social Work program. The School of Social Work is part of the MU College of Human Environmental Sciences.
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Editor's Note: In 2012, a team of University of Missouri Sinclair School of Nursing researchers, including Rantz and Galambos, received a $14.8 million grant from the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) to reduce hospitalizations of nursing home residents. The team received an additional $19.8 million grant to expand the nursing home improvement project. One goal of the project is to develop communication systems at nursing homes to ensure that consistent communication of residents' decisions about advance directives can take place.

University of Missouri-Columbia

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