Notwithstanding this variability, the message of this report is that each hospital should be held accountable for identifying its shortcomings and devising strategies to improve the quality and consistency of care at the end of life. The same holds for other organizations and settings of care.

Nursing Homes

The care of dying patients will be an increasingly important issue for nursing homes in future years as the number of older people most at risk for nursing home admission grows and as hospitals and managed care plans continue to minimize hospital stays. Home care agencies, however, are caring for some patients who might previously have been admitted to nursing homes, although the extent to which home care substitutes for inpatient care is debated and the growing cost of home care is creating increasing concern (see the discussion later in this chapter).

Between 1985 and 1995, the number of nursing home residents grew almost 4 percent to about 1.5 million people, but the number of residents per 1,000 people age 65 and over dropped (Strahan, 1997). The number of nursing facilities declined by over 12 percent. The total number of beds increased by about 9 percent but the number of beds per 1,000 population dropped. About two-thirds of nursing homes are for-profit organizations, many of them part of national or regional chains. About two-thirds of nursing homes are certified by both Medicare and Medicaid, and only 4 percent are not certified by either. The large number of facilities (around 16,000 in 1995) and, to some degree, their relative isolation from both the rest of the health care system and the community present some particular difficulties for quality monitoring and improvement.

During the 1970s and 1980s, an increasing amount of attention was directed to the quality of care in nursing homes and the integrity of nursing home management (IOM, 1986; Kane and Caplan, 1990). One result was the 1987 Nursing Home Reform Act, which set forth a variety of regulatory requirements and directions for improvement in nursing home care and management. Care for nursing home residents approaching death was not a major issue during this period. Rather, the focus was primarily on eliminating neglect and mistreatment, preventing physical and mental deterioration and restoring function to the degree possible, and respecting patient dignity and autonomy. As nursing homes attempt to market specialized services or units for care of Alzheimer's, postsurgery, and other patients, the mix of objectives and services will change from the more traditional emphasis of many facilities on generalized long-term care. How these changes might encourage or complicate improvements in end-of-life care is unclear.

Nursing home residents are, altogether, a heterogeneous group. For some patients admitted to nursing homes, death is expected within a rela-

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