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Objective:One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.Methods:We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care—advance care planning and pain management—and on residents' demographic and health status variables. Analyses tested for differences by race and age.Results:White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.Significance of results:To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management. [ABSTRACT FROM PUBLISHER]

Context: Death is common in nursing homes, but access to palliative care is limited. Objective: To test whether a quality improvement (QI) intervention in nursing homes increases hospice, pain management, and advance care planning. Design and setting: The QI intervention was tested in seven nursing homes using a prepoststudy design. Two additional nursing homes served as control sites. Participants: Nine nursing homes serving 1169 residents. Intervention: The intervention included recruitment and training of Palliative Care Leadership Teams in each facility, followed by six technical assistance meetings for team members. Hospice providers delivered six educational sessions for all nursing home staff using a structured curriculum. Teams received feedback of performance data on hospice enrollment, pain management, and advance care planning at 0, 3, and 6 months. Main outcome measures: Percentage of residents receiving hospice or palliative services, pain assessment, pain treatment among residents in pain, and documented advance care planning discussions. Results: Intervention facilities increased hospice enrollment from 4.0% of residents at baseline to 6.8% postintervention ( p = .01) and increased pain assessments from 18% to 60% ( p <.001). Among resident in pain, orders for nonpharmacologic pain treatments increased from 15% to 35% ( p < .001), but pain medication use did not change. Residents with in-depth discussions about end-of-life care increased from 4% to 17% ( p < .001). There were no significant changes in control sites. Conclusions: A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions. [ABSTRACT FROM AUTHOR]