Meeting palliative care needs in post-acute care settings: "to help them live until they die".

One fourth of US deaths take place in long-term care facilities. As the population ages and hospitals shorten length of stay, these settings will deliver more terminal care. Using an illustrative case of an older patient with metastatic melanoma whose life expectancy was weeks to months, we discuss when potential benefits outweigh the risks of transfer from the hospital to post-acute care settings. To improve continuity of care, we outline communication of treatment goals and orders that anticipate symptom escalation. We discuss criteria physicians can use to identify the settings most able to ensure access to high-quality palliative care. Physicians and patients must consider the advantages and disadvantages of inpatient hospice, nursing homes, and residential care facilities. Post-acute care settings vary in delivery of hospice and other palliative care services, professional nursing services, and support of activities of daily living. Finally, we discuss the evidence that palliative care can be improved in these settings, including innovations in advance care planning, staff training, and systematic changes in clinical care practices. Expanding, replicating, and disseminating these studies will be necessary to improve care for the growing number of persons who die in post-acute care settings.