Table 2.

Different approaches at low- and high-hospitalizing facilities

1. Case-by-Case Decision Making versus a Default Pathway
LOW-HOSPITALIZING FACILITIES	HIGH-HOSPITALIZING FACILITIES
They see the hospitalization as, ‘Well, if there’s one last glimmer, if there’s one last thing.’ One of the things we talk to them about is, when you get to this end stage — because for many of our people it is the end stage — what’s your goal? Is your goal treatment? Is your goal treatment with comfort? If your goal is comfort, then being treated in place is more likely to achieve that. (#201, social worker) I try to put whatever is going on with them in the context of the co-morbid conditions they have and get from the family what they would expect or what they would want to happen at the hospital . . . I try to say out loud: ‘does this make sense?’ (#703, NP)	The policy here is that if we can treat them here then we will, [but] every time somebody is changed clinically— like they’re sick — most of the nurses just call the doctor and tell them they’re sick. Of course, the doctor doesn’t really see the patient. The doctor will just say: ‘Okay, send them out.’ (#103, nurse) When you have a patient who has a change of condition in a facility, if you ever really question if the patient should be in the hospital, you should do that — you should send the patient to the hospital if you question that. (#304, physician)
2. Trying to Change Families’ Minds versus Deferring to Their Decisions
LOW-HOSPITALIZING FACILITIES	HIGH-HOSPITALIZING FACILITIES
The nurses will talk to [families], the social worker will talk to them, we’ll have meetings . . . If we can’t convince them — and we’re not trying to convince anybody to die, but we want to make them comfortable and really look realistically at the picture — we’ll often ask the APRN or the doctor to talk with them . . .We’re not trying to kill everybody. I don’t want you to think we’re trying to kill everybody. We just feel like it’s the most comfortable for them. (#701, administrator) We’ve worked as hard as we can to educate [families] and I wouldn’t say influence them, but if we do genuinely feel like it’s not in their best interest, we’ll work really hard to discourage someone who is making a bad decision. (#501, administrator)	It’s a tricky dynamic as far as treating, sending, keeping, but overall I think the patient and the patient’s family drives the decision-making. I give them all the options . . . I don’t think I have a huge influence on changing [their minds]. I think that has to happen within the family. (#101, NP) Even if I think that the patient is at a point where there’s not going to be much that they can do . . . I always end [the conversation] with: ‘But in the end it’s your decision what you want to do.’ It’s not my decision. Everyone has to make their own decision. (#303, PA) I don’t try to jam my viewpoint down on anybody. I just say, “these are things you should consider now.” (#301, administrator)