Zerzan J, Stearns S, Hanson L
Division of General Medicine, CB 7110, 5035 Old Clinic Bldg, University of North Carolina, Chapel Hill, NC 27599-7110, USA.
JAMA. 2000 Nov 15;284(19):2489-94. doi: 10.1001/jama.284.19.2489.
Nursing homes are the site of death for many elderly patients with incurable chronic illness, yet dying nursing home residents have limited access to palliative care and hospice. The probability that a nursing home will be the site of death increased from 18.7% in 1986 to 20.0% by 1993. Dying residents experience high rates of untreated pain and other symptoms. They and their family members are isolated from social and spiritual support. Hospice improves end-of-life care for dying nursing home residents by improving pain control, reducing hospitalization, and reducing use of tube feeding, but it is rarely used. For example, in 1997 only 13% of hospice enrollees were in nursing homes while 87% were in private homes, and 70% of nursing homes had no hospice patients. Hospice use varies by region, and rates of use are associated with nursing home administrators' attitudes toward hospice and contractual obligations. Current health policy discourages use of palliative care and hospice for dying nursing home residents. Quality standards and reimbursement rules provide incentives for restorative care and technologically intensive treatments rather than labor-intensive palliative care. Reimbursement incentives, contractual requirements, and concerns about health care fraud also limit its use. Changes in health policy, quality standards, and reimbursement incentives are essential to improve access to palliative care and hospice for dying nursing home residents. JAMA. 2000;284:2489-2494.
养老院是许多患有不治之症慢性病的老年患者的死亡场所，但临终的养老院居民获得姑息治疗和临终关怀的机会有限。养老院成为死亡场所的概率从1986年的18.7%上升到1993年的20.0%。临终居民经历着未经治疗的疼痛和其他症状的高发生率。他们及其家人与社会和精神支持相隔离。临终关怀通过改善疼痛控制、减少住院次数和减少鼻饲的使用，改善了临终养老院居民的临终护理，但很少被使用。例如，1997年，只有13%的临终关怀登记者住在养老院，而87%住在私人住宅，70%的养老院没有临终关怀患者。临终关怀的使用因地区而异，使用率与养老院管理人员对临终关怀的态度和合同义务有关。当前的卫生政策不鼓励对临终养老院居民使用姑息治疗和临终关怀。质量标准和报销规则为恢复性护理和技术密集型治疗提供了激励，而不是劳动密集型的姑息治疗。报销激励、合同要求以及对医疗保健欺诈的担忧也限制了其使用。卫生政策、质量标准和报销激励措施的改变对于改善临终养老院居民获得姑息治疗和临终关怀的机会至关重要。《美国医学会杂志》。2000年；284:2489 - 2494。
