Cancer Patients in US Nursing Homes: Quality of End of Life Care

Reviewer: Thomas Dilling, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: May 18, 2002

Presenter: V.M.P. Johnson
Presenter's Affiliation: Brown University Medical School
Type of Session: Scientific


  • As the American population ages, increasing numbers of Americans are receiving their end of life care in nursing homes.
  • Little information has been published regarding care in these nursing homes.

Materials and Methods

  • Secondary analysis was performed of the 1999 Minimum Data Set National Repository Data (includes information on 2.1 million individuals).
  • Specifically, the researchers analyzed advance care planning, pain management, use of hospice services, and the use of active treatment among nursing home residents with cancer.
  • These factors were analyzed by nursing home staff, which may introduce an ascertainment bias.
  • No information was available regarding the type of cancer or stage of disease in the patients.


  • Within 60 days of April 1, 1999, 188,380 nursing home residents (9%) had a cancer diagnosis.
  • Median age was 81 years. 57% were female.
  • 23% had weight loss, 26% were receiving IV medication, and 24% required supplemental oxygen.
  • 46% had a DNR order, though DNR rates varied widely by state, with a range of 17%-75% (p value highly significant).
  • 47% of patients were frequently in persistent, severe pain.
  • State variations in pain varied from 40-60%.
  • Palliative chemotherapy or radiation were provided to very few of these patients (4% and 5%, respectively).
  • 14% received parenteral or tube feedings.
  • 11% were deemed "terminally ill," but less than one third received hospice services.

Author's Conclusions

  • One in ten nursing home patients has a diagnosis of cancer.
  • Nearly half of these experienced persistent, severe pain.
  • There was great state by state variation in utilization of DNR orders or pain control.

Clinical/Scientific Implications

  • Further research needs to be done to better ascertain the reasons for variability in pain control and end of life care in different geographic states in the US.
  • Overall, it appears that hospice and other palliative medical services are grossly underutilized in the nursing home population.
  • Future interventions will need to address these deficits.

Oncolink's ASCO Coverage made possible by an unrestricted Educational Grant from Bristol-Myers Squibb Oncology.