Nursing home stays are common among older adults at the end of life (EOL) in the United States. Particularly for those with metastatic cancer, EOL care is complicated by the high morbidity burden, functional dependency, and/or cognitive impairment experienced by many of these patients. Aggressive disease-oriented interventions at EOL for people with metastatic cancer have a high personal and financial burden, with little or no benefit relative to cure or survival.
Previous studies on EOL care have not differentiated nursing home vs community-dwelling patients, leaving a gap in the literature on the subject. To address this gap, Dr Siran Koroukian and colleagues conducted a cohort study of 146,329 older adults with metastatic breast, colorectal, lung, pancreas, or prostate cancer from the Surveillance, Epidemiology, and End Results (SEER) database. The study compared markers of aggressive EOL care between patients who are nursing home residents and their community-dwelling counterparts. The primary outcome was receipt of aggressive EOL care, defined by the presence of any of the following variables in the last 30 days of life: any cancer-directed treatment, more than 1 emergency department visit, more than 1 hospital admission, or any admission to an intensive care unit.
In contrast to increased emphasis over the past decades on reducing aggressive EOL care—especially for nursing home residents—the study found that aggressive EOL care was more common for nursing home residents than for community-dwelling residents (64% vs 58%). The variables of aggressive EOL care that had higher prevalence among nursing home residents than community-dwelling adults were more than 1 emergency department visit (22.9% vs 20.3%), more than 1 hospitalization (14.3% vs 11.5%), and in-hospital death (39.0% vs 25.1%).
Ultimately, nursing home status was associated with 4% higher odds of receiving any marker of aggressive EOL care. The authors suggest multifactorial reasons for this, such as patient and family preferences and the capabilities of healthcare delivery systems.
Cancer-directed treatment was 10% lower for nursing home residents with metastatic cancer, reflecting a decision to decrease care for those patients. However, the authors did not uncover the reasons why such a decision was not associated with early enrollment in hospice, and suggest that a detailed qualitative study is needed to better understand the rationale for decisions surrounding hospital transfer in this patient population. When developing interventions to reduce aggressive EOL care, decision-makers should start by analyzing hospital admissions in the last 6 months of life and in-hospital deaths.
These findings point to a heavy reliance of nursing homes on hospital care, even for patients with metastatic cancer and those approaching death. The authors suggest that clinicians participate in multilevel interventions to decrease aggressive EOL care, targeting hospital admissions in the last 30 days of life and in-hospital deaths.