In nursing homes, nurses and aides play a crucial role in whether residents receive hospice care at the end of life and for how long that care is received, according to a qualitative, nongeneralizable study. 

Hospice utilization is on the rise in the United States, but hospice use varies widely. The average length of hospice care is decreasing, suggesting patients are being referred closer to death and not receiving the full benefits of hospice.

In this study, designed to look at how everyday processes in nursing homes affect hospice referrals, investigators interviewed nursing home nurses and aides, as well as hospice nurses, who knew how 32 specific nursing home decedents at seven nursing homes in one state had been referred to hospice. They also interviewed the directors of nursing at the nursing homes.

None of the nursing homes had written procedures for regularly assessing the terminal status of patients or for making referrals to hospice, and none had formal protocols for communicating with doctors about a patient’s hospice eligibility. Three staff factors shaped hospice referrals and the timing of those referrals:

1. Skill in recognizing signs of terminal decline;
2. Beliefs about hospice; and
3. Staff initiative in raising the possibility of hospice care with patients, families and doctors.

This study recommends staff training on earlier identification of terminal decline, the breadth and benefits of hospice care, and taking initiative to raise the option of hospice earlier. The authors call for larger scale research on their findings, prospective observational study to remove the limitations of memory inherent in their methodology, and research on additional factors that may affect whether and when hospice referrals are made, such as, nursing home staff organizational patterns and the characteristics of individual facilities and patients.