Nursing home resuscitation policies and practices for residents without DNR orders

The purpose of this study was to explore the policies and practices of nursing homes with respect to the resuscitation of residents who do not have a do-not-resuscitate (DNR) order. Responses from a survey of 36 facilities revealed that most residents had DNR orders and most facilities were capable of providing basic cardiopulmonary resuscitation (CPR). Less than 30% had performed CPR in the past 6 months, and 22.8% had no written CPR policies. More facilities required CPR in witnessed arrests of non-DNR residents (79.3%) than in unwitnessed arrests (24%). Methods for identifying CPR status need improvement to enable accurate identification and prompt resuscitation of residents who want CPR.     

Death in the hospital

OBJECTIVE: To examine symptoms and treatments among hospitalized adults in the last 2 days of life. METHODS: Review of 72 consecutive medical records of patients who died at an academic medical center and 32 consecutive medical records of patients who died at an affiliated Veterans Affairs hospital. Medical records were examined for documentation of symptoms, treatment, and orders to limit the use of life-sustaining interventions. RESULTS: The 104 patients who died had an average age of 68.9 years and 70 (68%) were men. The majority had neoplasms or acquired immunodeficiency syndrome, cardiovascular disease, and end-stage lung disease; the remainder died of other acute or chronic illnesses. In the last 2 days of life, pain was noted in 49 patients (46%). Dyspnea (n=53) and restlessness or agitation (n=50) were documented in 51% of the patients. In the last 48 hours of life 12 patients (12%) underwent an attempt at resuscitation, 26 patients (27%) were receiving ventilatory support, and 18% were restrained. Nearly half of the patients (48%) had an order or progress note specifying "comfort measures only" (CMO). Patients with CMO, compared with those without such orders, had similar levels of pain, agitation, and dyspnea. Patients with CMO were less likely to be in an intensive care unit (P=.001), receive ventilatory support (P=.001), receive antibiotics (P=.009), or be weighed (P=.001). CONCLUSIONS: Baseline information with which to begin improvement of care for dying individuals was obtained through a brief retrospective chart review. While patients with CMO receive less aggressive care, no specific process was used to provide comfort care. The evaluation and testing of processes of care for dying patients are necessary to begin the improvement of care. We provide baseline data about processes and outcomes of care in our hospitals.     

Mortality of the institutionalized old-old hospitalized with congestive heart failure

BACKGROUND: Congestive heart failure is a major cause of mortality and morbidity in the elderly but the disease impact on the oldest and sickest population has not been defined. OBJECTIVES: To review the mortality and hospital readmission rate of institutionalized elderly persons with congestive heart failure and to examine the relation of baseline characteristics to subsequent clinical outcomes. METHODS: This was a retrospective analysis based on chart review of 231 residents of the Philadelphia (Pa) Geriatric Center (63 congregate housing tenants and 168 nursing home residents) 80 years and older, hospitalized with congestive heart failure from 1989 to 1995. Patients' demographic data and clinical, electrocardiographic, and echocardiographic findings were obtained from their initial (index) hospitalization records. Subsequent outcomes were obtained from their outpatient (nursing home or office) records. RESULTS: Thirteen percent died during the index hospitalization but the total mortality during the follow-up period was 87%. One hundred forty-six patients (63%) died in the first year with a mean +/- SD survival of 4+/-4 months and a readmission rate of 3.9 per patient-year. Eighty-five patients survived the first year with a readmission rate of 1.2 per patient-year and 54 patients subsequently died, with a mean +/- SD survival of 28+/-12 months. The first-year decedents and survivors were comparable in sex, age, medical history, and electrocardiographic findings. However, patients who died in the first year, compared with survivors, were more likely to be nursing home residents (81% vs 59%), have New York Heart Association class IV heart failure (54% vs 32%), have impaired left ventricular function by echocardiogram (53% vs 32%), and have renal insufficiency (32% vs 11%). CONCLUSIONS: Very elderly persons with congestive heart failure had a guarded long-term prognosis. Nursing home residency, class IV heart failure, impaired left ventricular function, and renal insufficiency were associated with higher risk for early death and repetitive hospitalizations.     

Communicating do-not-resuscitate orders with a computer-based system

BACKGROUND: Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form. METHODS: Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. RESULTS: For the 147 patients, the computer-based system in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was "substantial" or "almost perfect" as measured by the K statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff. CONCLUSION: A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.     

Arginine vasopressin levels in nursing home residents with nighttime urinary incontinence

OBJECTIVES: To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents. DESIGN: Case series. SETTING: Four nursing homes and two board and care facilities. PARTICIPANTS: Sixty-two nursing home residents and 27 board and care residents. MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay. RESULTS: Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios > or = 50%. Forty-nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios > or = 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences. CONCLUSION: Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.     

Terminal care of the very old. Changes in the way we die

BACKGROUND: This study examines the use of advance directives, limitations of treatment, and medical interventions during the terminal hospitalization of the old-old. Study periods before and after the implementation of the Patient Self-Determination Act of 1990 were chosen to determine if there has been a change in terminal care. METHODS: Chart review was performed for all patients 85 years and older who died in the hospital during 1988 and 1993. Patient characteristics, presence of advance directives, do-not-resuscitate orders, and other treatment limitations were noted as were interventions listed in the Medical Directive. RESULTS: Less than 12% of the 167 study patients had an advance directive. Length of stay for these terminal admissions decreased from 18.5 to 9.6 days. Ninety-five percent of the patients were "do not resuscitate" by time of death, but orders were written sooner in 1993--75% within 24 hours of admission. Patients with early do-not-resuscitate orders had fewer high-intensity interventions. More patients had "comfort measures only" during the study period. An overall decrease in high-intensity interventions and a specific decrease in the use of transfusions, invasive tests, minor surgery, and cardiopulmonary resuscitation was seen. CONCLUSION: Patients 85 years and older are receiving fewer high-intensity interventions during their terminal hospitalizations. More attention is being paid to comfort and few are receiving cardiopulmonary resuscitation. There is little reference to formal advance directives in decision making for these patients.     

The frequency of "do-not-resuscitate" order in aged in-patients: effect of patient- and non-patient-related factors

OBJECTIVE: The purpose of this study was to examine the effect of patient- and non-patient-related factors (co-morbidity, demographics, and method of surveillance) on the frequency of "do-not-resuscitate" (DNR) orders in aged inpatients. METHODS: On a geriatric ward, during three different periods within 1 year, we used two different methods of data collection (with or without a form) and two different time-frames (prevalence or incidence) in studying the frequency of DNR orders, demographic data and the Pre-Arrest Morbidity (PAM) Index. RESULTS: In a sample of 261 patients the DNR decision was related to patient-related factors, including the PAM score and age. Only 3 patients with a score above 4 had no DNR order and in the group of 142 patients > 83 years 85 (59.9%) had a DNR order, compared to 52 (43.7%) of the 119 patients of 83 years or less (p < 0.05). In contrast, gender and marital status were not related to the presence of a DNR order. The variables PAM score, age, form and time-frame classified 76.6% of the cardiopulmonary resuscitation (CPR) decisions correctly and 71.5% of the DNR decisions correctly. Without attention to the resuscitation decision, the written DNR order frequency decreased significantly from 64-59% to 23%. An explanation for this variance may be the passive process of data collection, a non-patient-related factor. CONCLUSIONS: The DNR decision is related to the PAM index score and age. The variance in DNR decisions is partly related to the method of data collection, a non-patient-related factor in DNR decision-making. Without attention to the DNR/CPR decision, the DNR frequency decreased markedly.     

Determinants of subsequent home health care nursing service use by hospitalized patients with cancer

BACKGROUND: The authors examined the extent to which specific patient characteristics and length of hospital stay were capable of independently explaining the use of home health care nursing services by hospitalized patients with cancer after discharge. METHODS: The current study represents a secondary analysis of a data set originally gathered to identify the home health care needs of patients with cancer. The sample involved 87 patients with cancer who received home health care after hospitalization and 43 patients who did not receive such services. RESULTS: A logistic regression analysis indicated that home health care use was related to patient age, length of hospital stay, and level of symptom distress. Specifically, the likelihood of home health care use was found to increase among subjects older than 50 years of age, subjects with hospital stays of more than 7 days (apparently related to surgery), and those who experienced moderate to high levels of symptom distress. CONCLUSIONS: The results indicate a need for home health care nurses to be skilled in the management of cancer symptoms and in the complex problems commonly experienced by the postsurgical patient with cancer.     

A report of an investigation of end-of-life care practices in health care facilities and the influences on those practices

In 1992, 82.2% of deaths in Alberta occurred in acute care hospitals or continuing care facilities. This paper outlines the end-of-life care of adult inpatients who died that year in four such facilities (n = 137). CPR was an infrequent end-of-life treatment modality (2.9%), in stark contrast to the extensive use of other medical technologies. Almost every inpatient (94.2%) died with one or more technologies in continuous operation. Although reasons were infrequently given, the desire to promote patient comfort was the most frequent influence on end-of-life technology use. The findings of this study raise issues for debate and further investigation. Chief among these issues is whether or not medical technologies promote comfort during the dying process.     

Usefulness of ultrasound in Sudeck''s atrophy of the foot

A study was carried out to evaluate burn nurses' attitudes toward do-not-resuscitate (DNR) orders. Questionnaires were submitted to 57 staff members, 52 of whom responded. Seventy-five percent of those responding ranged in age from 30 to 49 years. Seventy-one percent were registered nurses or licensed practical nurses. Sixty-five percent of the respondents had been in health care for more than 10 years; 25% had been in burn care for more than 10 years. Fifty percent were Protestants. Thirty-seven percent of the total described themselves as very religious. Ninety-four percent of respondents felt that DNR orders are sometimes appropriate. Eighty-eight percent felt that DNR decisions should not be made solely by the physician. Ninety-five percent felt that input from patients, family members, or both is essential. Having formal ethics committees make such decisions was opposed by 75% of the respondents. Fifty-six percent felt nurses should be involved in such decisions and 21% opposed such involvement. There was considerable uncertainty, disagreement, or both about whether a DNR order should include stopping all medical treatment, ventilators, intravenous fluids, gastric feedings, and medication. The study indicated statistically significant support for the view that DNR orders are appropriate in some cases. Which patients should be given DNR status and who should make the decision about writing DNR orders were more controversial questions.     

Resident training in nursing home care: survey of successful educational strategies

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs. DESIGN: A mail survey with three follow-up mailings. PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs. MEASUREMENTS: Open- and closed-ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested. MAIN RESULTS: Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill-based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended. CONCLUSIONS: Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

A cost and value analysis of two interventions with incontinent nursing home residents

OBJECTIVE: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences. DESIGN: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance. PARTICIPANTS: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value. MEASUREMENT: The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room). RESULTS: Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers, CONCLUSION: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.     

What is wrong with end-of-life care? Opinions of bereaved family members

OBJECTIVE: To describe family perceptions of care at the end of life. METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care. RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%). CONCLUSION: Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.     

Aging increases CD8 T cell apoptosis induced by hyperstimulation but decreases apoptosis induced by agonist withdrawal in mice

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.     

Longitudinal weight changes, length of survival, and energy requirements of long-term care residents with dementia

OBJECTIVE: We hypothesized that institutionalized patients with dementia, who frequently have feeding problems and require supervised and assisted feeding, would lose more weight during their residency than nondemented, independently functioning residents and have compromised survival. To test this hypothesis, we examined the survival and longitudinal changes in weight of two cohorts of institutionalized residents with dementia and compared these cohorts with a cohort of nondemented residents. We also measured the resting energy expenditures of a subset of the subjects with dementia as an indicator of their energy needs. DESIGN: A longitudinal cohort study with retrospective baseline chart review and subsequent follow-up of monthly weights and mortality over 4 years. SETTING: A 725-bed long-term care institution with specified levels of care. SUBJECTS: Two cohorts of residents with dementia, one consisting of subjects who required total care throughout their institutional stay (n = 31) and another group who did not initially require total care (n = 48); these were compared with a cohort with normal mentation who were functionally independent in their daily activities (n = 26). The total number of subjects was 105. MEASUREMENTS: Demographics, medical problems, and medications by chart review; functional and mental status evaluations; longitudinal monthly weights and mortality for the 48-month study period; and resting energy expenditures by indirect calorimetry. MAIN RESULTS: Residents with dementia had lower weights on admission and throughout their stay than nondemented, independently functioning residents, and they were more likely to have a weight loss of 10 lbs or more at some point during the 4-year study period. However, their mean weights did not change during the study period. The mean survival from admission of those demented residents who died was more than 3 years. Resting energy expenditures of women residents with advanced dementia were 12% lower than predicted from the Harris Benedict equations. CONCLUSION: Dementia is not necessarily associated with unremitting weight loss during institutionalization despite the frequent occurrence of feeding difficulties and temporary weight loss. This may be caused partly by the lower than expected resting energy expenditures and, hence, energy needs of affected residents as their dementia progresses. Demented residents weighed significantly less than nondemented, independently functioning residents throughout their institutional stay. Nevertheless, nursing staff are able to maintain weight and survival for extended periods even in very impaired residents.     

Linking level of care to level of need: Assessing the need for mental health care for nursing home residents.

What are the mental health status and active treatment needs of nursing home residents? A stratified random sample of 828 residents in 25 facilities serving Medicaid recipients was assessed for levels of physical and psychosocial functioning. Although 91.2% had sufficiently high levels of medical and physical care needs to justify nursing home placement, 79.6% also had moderate to intense needs for mental health care. Older residents, relative to their younger counterparts, had more intense medical and mental health care needs. It was also found that psychiatric diagnosis was a poor indicator of mental health service needs, particularly among elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Care of persons with AIDS in the nursing home

BACKGROUND: AIDS is becoming a chronic illness for some patients whose significant accumulated functional impairments may limit community-based care. Nursing homes can provide an appropriate level of care, although reported experience caring for persons with AIDS in this setting is limited. METHODS: A retrospective case-series review was conducted in a 242-bed community teaching nursing home to describe the initial 26-month experience in providing care for patients with AIDS requiring nursing home admission. RESULTS: A total of 42 admissions by 32 patients with AIDS (mean age = 33.5 years, 81% male) involved a shorter length of stay (mean 63.1 days) and higher numbers of medications (mean = 11.2), facility charges (mean $11,971/admission, $189/day), and greater clinical management complexity than usual nursing home patients. Thirteen patients were discharged, seven for rehospitalization and six into community settings, although ultimately 29 of the 32 patients died in the facility. CONCLUSIONS: AIDS care in the nursing home presents significant, distinct challenges in complex management and terminal care prioritization.