Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation

J Palliat Med. 2008 Mar;11(2):217-25. doi: 10.1089/jpm.2007.0147.


Objectives: The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death.

Design: PROGRAM DESCRIPTION and evaluation using a retrospective chart review before and after implementation of the MAPP program.

Participants: NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72).

Program description: The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation.

Program evaluation: Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death.

Results: Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02).

Conclusion: An intervention designed to address the end-of-life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.

MeSH terms

  • Advance Directives
  • Aged, 80 and over
  • Critical Illness / mortality*
  • Critical Illness / therapy*
  • Female
  • Health Services Needs and Demand
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Nursing Homes*
  • Palliative Care / methods*
  • Prevalence
  • Program Development
  • Retrospective Studies
  • Risk Factors