Whether being admitted to a nursing home increases the risks of death is a difficult question. The current state of literature provides rich information on the risks and problems facing elderly nursing home residents. This paper is a review of literature intended to reconsider the risks of mortality in elderly nursing home residents. The following themes are included: inappropriate medication, falls, dementia, acquired infections, and unnatural deaths. Implications for the study of death risks in nursing home settings are provided.
Keywords: nursing home, death, elderly, nursing, risks, care.
Death in a Nursing Home
The problem of deaths in nursing homes has long been a matter of public scrutiny. In 1992, the number of residents in U.S. nursing homes exceeded 1.5 million, and the percentage of the elderly residing in nursing homes was increasing with age (Corey, Weakley-Jones, Nichols & Theuer, 1992). In 1992, only two percent of the elderly aged 65-74 was expected to end their lives in a nursing home, compared to almost 22% older than 85 (Corey et al., 1992). Today, the number of nursing home residents has not changed: Centers for Disease Control and Prevention (2012) estimate that around 1.5 million older people currently live in nursing homes. Despite the recent advances in medical technology, the problem of deaths in nursing homes remains an object of serious concern. The goal of this review is to see whether nursing homes increase the risks of mortality in their elderly residents. The problem was selected mainly due to the lack of sufficient data and the growing pressure to contain medical costs at the federal level. The results of the proposed investigation may help nursing home professionals improve the quality and safety of care, while also balancing and even reducing its cost. This review reconsiders the problem of deaths in nursing homes from an empirical, mainly quantitative, perspective and is intended to create a solid basis for the implementation of future evidence-based care projects in nursing homes. The review is limited to deaths in nursing homes and does not include the problems of deaths in nursing home residents admitted to hospitals due to their health state.
On March 4, 2013, Fox News reported a death case in a facility for elderly patients located in California. According to Rafferty (2013), an elderly female resident of Glenwood Gardens in California died because the nurse refused to provide timely medical assistance. The nurse refused to perform a life-saving procedure on the premise that such steps were prohibited by the nursing home's policy (Rafferty, 2013). The records of the conversation between the nurse and the 911 operator indicate that the nurse openly refused to perform CPR, thus violating a whole set of patients' ethical rights and damaging the image of nursing as a profession aimed to promote patients' beneficence and lives.
Almost at the same time, Champaign County released a report from the community's Nursing Home board of directors. The report showed that, over the three months preceding its publication, the number of deaths in the nursing had substantially increased. At least 60 deaths were registered in the community nursing home in December-February, which was much higher than the accepted average of 5.3 deaths per month (The News-Gazette, 2013). The problem of deaths in nursing homes is both obvious and underexplored. Reasons why nursing home residents may face higher risks of death compared to home settings also remain unclear. However, the problem has profound implications for the entire healthcare system, for the communities which have nursing homes, and for the current understanding of nursing as a caring profession. On the one hand, the growing incidence of deaths in nursing homes is likely to lead to a substantial increase in lawsuits and litigation costs. "Lawsuits against nursing homes are a relatively new phenomenon" (Stevenson & Studdert, 2003, p.219). Nursing homes need to divert considerable resources to provide adequate legal defense and pay compensations. On the other hand, communities direct huge resources to support the long-term functionality of their nursing homes, and the growing number of deaths is likely to taint their reputation as safe places to live and obtain quality care (The News-Gazette, 2013). Finally, looking at the problem holistically, the problem of deaths in nursing homes undermines the very idea of nursing as a profession that brings satisfaction and serves the health and life needs of nursing home residents. Apparently, better knowledge of the problems facing nursing home residents is required to develop adequate solutions and protect their safety and health.
It should be noted that death as an outcome of nursing home care is an essential indicator of care quality in these settings. Back in 1977, Linn, Gurel and Linn explored the relationship between deaths and care quality indicators in nursing homes. According to Linn et al. (1977), it is always desirable to have better information about patient outcomes. Given the diversity of nursing home residents, mortality and death exemplify a viable approach to measuring the quality of care. It is not always easy to predict patients' recovery potentials or study their progress. At the same time, death alone cannot be a feasible measure of care quality in nursing homes, mainly because, for many patients admitted to nursing homes, death is the most likely prognosis (Linn et al., 1977). Linn et al. (1977) state that "one of the primary functions of a nursing home is to provide humane care for dying or severely ill patients" (p.338). Therefore, the incidence and risks of deaths in nursing homes should be measured in terms of the expectations and prognoses, as well as in terms of the quality and appropriateness of care provided before death.
Most researchers who explored the problem of death in nursing home residents chose to consider the risks of one or several health complications that might be responsible for those risks. Rubenstein, Josephson and Robbins (1994) reviewed the incidence and risks of falls in nursing homes and their relation to the risks of death among nursing home residents. Rubenstein et al. (1994) wrote that three fourths of all deaths caused by falls occurred in individuals aged 65 years and older. In healthcare institutions and nursing homes, the risks of falls are abundantly documented: compared to the elderly living at home, nursing home residents face the risks of falls that are three times higher (Rubenstein et al., 1994). The mean incidence of falls in nursing homes was estimated at 1.5 per nursing home bed (Rubenstein et al., 1994). Once fallen, the elderly nursing home resident has much higher risks of fatality than a younger person with a similar trauma (Rubenstein et al., 1994). Nursing homes have higher rates of hip fracture among their residents and higher mortality rates due to hip fracture than the same indicators in community-based elderly residents (Rubenstein et al., 1994). These results suggest that nursing homes increase the risks of death, but many questions still remain unanswered. Rubenstein et al. (1994) are right, when saying that the percentage of frail residents in nursing homes is much higher than in the rest of the community. Besides, only 1 in 5 fractures in elderly falls and fractures takes place in nursing homes (Rubenstein et al., 1994). These findings alone cannot support the thesis that the risks of death in nursing homes are higher, although they confirm the need to study the problem in detail.
Another problem explored in relation to deaths in nursing homes is that of dementia. Many residents are admitted to nursing homes due to their health state and require that their prognosis and the need for quality palliative care are evaluated (Mitchell et al., 2004). Still, most nursing homes and hospices report difficulties estimating the life prognosis in the enrollees, who have been diagnosed with dementia (Mitchell et al., 2004a). Even more disturbing are the emerging complaints that the quality of dementia care in nursing homes is below the accepted standards. This problem was thoroughly investigated by Mitchell, Kiely and Hamel (2004b).
The problem of death in patients with dementia is particularly acute, bearing in mind that almost 90% of them are institutionalized before death (Mitchell et al., 2004b). According to Mitchell et al. (2004b), older patients with dementia admitted to nursing homes often have to undergo burdensome and unnecessary nonpalliative procedures, even though their life expectancy is limited. In nursing homes, which are intended to serve the end-of-life needs of geriatric patients, dementia is often not recognized as a terminal condition (Mitchell et al., 2004b). Residents with advanced dementia living in nursing homes are more likely to have pressure ulcers, be treated with psychotic medications and be exposed to restraints than the residents with terminal cancer (Mitchell et al., 2004b). The provision of inappropriate nonpalliative medical measures to patients with dementia, including phlebotomy and feeding tubes, can potentially be related to higher risks of mortality in nursing homes: 25% of dementia patients in nursing homes were found to have died with a feeding tube compared to only 5% of residents with cancer (Mitchell et al., 2004b). Even then, the relationship between dementia care and death risks should be profoundly analyzed to exclude the influence of other potentially confounding factors, such as prognosis and the severity of the diagnosis.
The risks of death in nursing home are often considered through the prism of other diagnoses, including nursing-home acquired pneumonia (NHAP). This problem was thoroughly analyzed by Mylotte (2002) and Beck-Sague, Banerjee and Jarvis (1993). Beck-Sague et al. (1993) conducted the first population-based study to analyze the risks of infections in nursing homes and their relation to mortality. The results showed that bedbound residents of nursing homes faced higher risks of pneumonia (54.5 per 100 discharges), whereas residents with indwelling catheters were also exposed to severe risks of urinary tract infections (Beck-Sague et al., 1993). NHAP also increased the risks of death in a nursing home (35% vs. 28%) (Beck-Sague et al., 1993).
Today, pneumonia is claimed to be the second most common cause of mortality in nursing homes, as well as the most common reason why nursing home residents are discharged to hospitals (Mylotte, 2002). Mylotte (2002) also writes that the nursing home residents who survive pneumonia experience significant morbidity. These results suggest that pneumonia is quite common in nursing home, but its causes and relation to the quality of nursing home care remain unclear. Beck-Sague et al. (1993) suggest that the risks of pneumonia-related mortality in nursing home residents may be associated with delays in evaluating the symptoms of the infection and providing timely treatment and support. The systems of infections controls in nursing homes are also imperfect: proven methods to reduce the risks of infections are rarely used (Beck-Sague et al., 1993). All these aspects imply that being in a nursing home is a more dangerous endeavor than spending the last days of life at home.
The analysis of unnatural deaths in nursing homes could add to the statistical findings presented above. Corey et al. (1992) claim that a significant amount of deaths in nursing homes is not investigated, because most residents suffered from serious medical illnesses. Corey et al. (1992) presented the analysis of nine accidental and homicidal deaths in nursing homes, their main causes including asphyxia, restraints devices, scald burns, airway obstruction, and hypothermia. Chest restraints were used improperly, leading to death. Failure to provide adequate life support was also responsible for one death. Poor enforcement of the existing legislation impedes the implementation of effective life support systems in nursing homes (Corey et al., 1992). Inappropriate medication prescriptions also increase the odds of being discharged to a hospital or dying the same month or next (Lau, Kasper, Potter, Lytes & Bennett, 2005). Statistically, 40% of nursing home residents face inappropriate drug choices, 13% experience drug-disease interactions, and 11% are compelled to take excess doses (Lau et al., 2005). At least 30% of all nursing home residents have to take inappropriately prescribed medications through their entire stay (Lau et al., 2005). Nursing homes that have regulatory difficulties are more likely to have registered unexpected or sudden deaths (Keay, Taler, Fredman & Levenson, 1997). Therefore, it is quality of care that matters and predetermines the likelihood of death in a nursing home.
Pros and Cons of the Issue
The pros and cons of the issue are obvious. On the one hand, the community has the right to know what is happening in nursing homes and how their professionals manage the quality of medical care provided by elderly residents. Compared to community-based elderly residents, those who are admitted to nursing homes experience higher risks of infections and mortality due to the absence of life support systems. In most cases, it is not residents' incapacitating condition or frail state but the use of inappropriate medications, incorrect nursing decisions, or complete indifference towards nursing home residents that result in their death.
On the other hand, the relationship between nursing home admission and the risks of death is not straightforward. This relationship is moderated by a large number of confounding factors. The initial life prognosis plays one of the major roles (Linn et al., 1977). The frail state of most nursing home residents should not be ignored. Besides, that more residents die in nursing homes than in community settings does not tell much about the problem: according to Van Rensbergen, Nawrot, Hecke and Nemery (2006), the mere presence of a nursing home in the local community predicts higher percentage of the elderly, who die within the institution. The study of death risks in nursing homes may be costly and time-consuming, but it has profound implications for the quality of nursing home care. The problem must be investigated in detail because, regardless of the physical state in which elderly people are admitted to nursing homes, they have the right for adequate and humane nursing care before they die (Linn et al., 1977).
Whether being admitted to a nursing home increases the risks of death is an open question. The current state of literature raises many questions regarding the quality and professionalism of medical care provided to nursing home residents. Nursing homes are claimed to increase the risks of infections, inappropriate medication prescriptions, falls, and unnatural deaths. Apparently, it is not prognosis or residents' frail state but the poor quality of care, unprofessionalism and noncompliance that result in so many deaths in nursing home settings. Still, a more detailed analysis of the factors, which moderate the relationship between nursing home admissions and death risks, should be performed.