(P48) Reduction of Non-Beneficial Life-Sustaining Treatments in a Nursing Home

Objective/Aim: Decrease number of non-beneficial medical treatments (NBT) for nursing home (NH) residents with advanced life-limiting illnesses and also enrollment in palliative care by 30% over a 12-month period via an interdisciplinary team (IDT) approach to MOLST (Medical Orders for Life-Sustaining Treatment) bedside discussions.

Background: The MOLST form provides an ideal framework for NH residents to express wishes on life-sustaining treatments at end-of-life. The term NBT indicates treatments such as cardiopulmonary resuscitation, intubation with mechanical ventilation or tube feeding that offer little or no likelihood of benefiting these residents due to their declining health, typified by those with advanced, terminal stage dementia. Due to staff time constraints and lack of communication skills, MOLST discussions often fail to capture NH residents’ wishes. NBT are often rendered which prevent or postpone initiation of palliative care.
As our large public NH is comprised mainly of racial-ethnic minorities, adversely impacted by social determinants of health, our equity lens focused on improving participation in palliative care for this population, which studies show have lower acceptance of palliative care. This is in keeping with the PALTC mission to help overcome inequities in access to quality post-acute care for racial-ethnic minorities.

Quality Improvement

Methods: We used the PDSA (Plan, Do, Study, Act) QI methodology. Our approach focused upon staff education and IDT communication strategies. Our hypothesis, based on a best practice model, was that our culturally diverse project team of highly dedicated professionals could build trust and shared understanding with these NH residents and families to facilitate resident-centered palliative care discussions. We implemented this project initially in a sub-acute pilot unit. We then expanded it to our memory care units.

Results: In the pilot unit, from 1/1/22 to 6/30/22, we identified 11 appropriate palliative care candidates, conducted IDT bedside rounds and enrolled all 11 in our program, while eliminating NBT in 6 of the 11 (54%), and in 5 of the 6 (83.3%), added MOLST orders to either avoid or limit acute care transfers. By the end of the 3rd quarter of 2022, we achieved a 33% net increase in enrollment in palliative care, compared to 2021, with 82% of new enrollees from racial-ethnic minorities.

Conclusions: This project was highly successful in enrolling racial-ethnic minorities in palliative care and in eliminating NBT in keeping with our equity lens. In terms of cost savings, estimated reduction in future acute care transfers could amount to tens of thousands of dollars. The next step will be to expand this project to our remaining NH units. We will then consider expanding it to the other post-acute facilities in our health care system.