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Normalizing hospice in long-term care

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“In the Orient, dying is a requirement. In Europe, dying is inevitable. In America, dying appears to be an option.” –Kerry Cranmer, MD, CMD, AMDA

In nursing homes, dying is illegal. That’s a provocative statement, but one that Crossroads Hospice president Perry Farmer owned in his presentation of a recent Long-Term Living webinar on the normalization of hospice in long-term care. OBRA ’87 regulations decree that nursing homes improve or maintain a resident’s function. But with 20 percent of all U.S. deaths taking place in nursing homes, the critical need for dedicated hospice care cannot be ignored.

And yet SNF staffs are not always adequately trained to support hospice. Hence Farmer promotes what he terms “reality orientation” for staff and residents and their loved ones.

“Shouldn’t hospice and long-term care be great partners in this process?” Farmer said. “Why are they often at odds?”

There are a couple reasons for this friction, he proposed. First, one needs to understand the difference between curative care and palliative care, two divergent philosophies that drive resident care. Curative care is a substance or treatment that can restore health. Palliative care involves alleviating pain and symptoms without eliminating the cause. In addition to easing suffering, hospice involves dealing with spiritual and emotional issues at the end of life.

And a second reason for the friction, “We don’t want people to decline in our nursing homes even though they do—and hospice charts one way,” Farmer said.

Successful LTC facilities are able to create an environment where hospice is just as “normal” as any other referral, Farmer maintains. As you tour families through the dining room, activities area and therapy space it is just as important to introduce them to your hospice. “This will alleviate their fears, and more importantly provide the first steps of normalization and reality orientation,” Farmer said. It involves identifying goals and mapping expectations. And, “your clinical care team must be preparing for the inevitable at every care plan meeting,” Farmer advised.

Misconceptions about hospice make referral difficult, Farmer said. “Services such as physical therapy, speech therapy and dementia units are all examples of extended care services. Hospice also is an extended care service,” Farmer said.

In addition to preparing for the inevitable at every care plan meeting, providers should have knowledge of disease progression and be able to convey that progression to the resident and family so they’ll understand what’s next and normal—to alleviate fears through knowledge.

To learn more about hospice in long-term care, including detailed guidelines in identifying goals and mapping expectations for the major hospice diagnoses, register for the archived webinar here.

Patricia Sheehan

Patricia Sheehan


Patricia Sheehan wrote for Long-Term Living when she was editor-in-chief. She left that...



The important relationship between nursing home staff and the hospice philosophy and staff can't be emphasized enough. I appreciate this post for addressing that. The quality of end-of-life care for any patient depends on the context in which the care is given. In the context of a nursing home, perceptions of staff members regarding the hospice philosophy and the implementation of that philosophy greatly impact a potential hospice patients’ experience. This includes the referral or non-referral of patients to hospice care and the timing of those referrals.

In a study at Southern Illinois University Edwardsville, an understanding of factors influencing hospice referrals, nonreferrals, and timing of referrals was researched. Cross sections of staff members from seven nursing homes and two hospices were interviewed with the following results:

1) Nursing home staff members’ recognition of terminal decline, beliefs about hospice, and the initiatives they took “significantly influenced” patients’ referrals to hospice care and the timing of their referrals.

2) When death was perceived as unexpected (familiar signs not recognized by staff members), hospice referrals were delayed.

3) When nursing home staff members believed that hospice care was only for a crisis at the end of life or that hospice care did not add to nursing home care, hospice referrals were delayed.

4) Patients received longer hospice care when staff members believed hospice care complemented nursing home care and when staff members took the initiative to raise the option of hospice care.

Ongoing hospice training for nursing home staff members is critical for this partnership to be successful. I emphasize ongoing because, in my experience as a hospice volunteer for many years, regular staff turnover demands this. Without ongoing training, the quality of end-of-life care for potential hospice patients is jeopardized.

Frances Shani Parker
Hospice and Nursing Homes Blog