Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life.

Caroline Stephens,Charlene Harrington,Christine Ritchie,Sei J Lee,Elizabeth Halifax,Janet Shim,Nhat Bui

doi:10.1155/2015/893062

Abstract

Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

Highlights

Transfers of frail nursing home (NH) residents to and from the emergency department (ED) are common and costly and expose vulnerable residents to the well-documented risks associated with care transitions [1,2,3,4,5,6,7]
Providers reported that families often reacted to resident changes in condition as crises and that this precipitated their efforts to push for hospital transfers
Nursing home (NH) health care providers further related that they often made transfer decisions against their best clinical judgment because of this family influence and for fear of potential repercussions. An example of this tension is described here by a NH physician: “They wanted to take him to the hospital, clearly, but I didn’t want that. . .family has a lot of influence

Summary

Introduction

Despite increasing legislation to monitor and enforce NH standards and quality of care over the past decade, the number of ED visits by NH residents has increased 12.8%, from 1.9 million to 2.1 million visits, and there has been no significant change in rates of potentially preventable ED visits [8] Many of these burdensome care transitions occur in the last 6 months of life [9, 10] or are for symptoms or conditions that can be safely and effectively treated in the NH setting [11,12,13,14]. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers

Methods

Results

Discussion

Conclusion