Palliative and Supportive Care

Original Articles

End-of-life care in nursing home settings: Do race or age matter?

Kimberly S. Reynoldsa1a3 c1, Laura C. Hansona3, Martha Hendersona4 and Karen E. Steinhausera2a5

a1 UNC Project, Lilongwe, Malawi

a2 Health Services Research and Development Service, Durham VA Medical Center, Durham, North Carolina

a3 School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

a4 School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

a5 Department of Medicine, Centre for Palliative Care, Duke University, School of Medicine, Durham, North Carolina


Objective: One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.

Methods: We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care—advance care planning and pain management—and on residents' demographic and health status variables. Analyses tested for differences by race and age.

Results: White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.

Significance of results: To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.

(Received December 07 2006)

(Accepted May 04 2007)


c1 Address correspondences and reprint requests to: Kimberly S. Reynolds, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. E-mail: