Home Hospice Providers Offer Best Practices for End-of-Life Care

New research from the Birmingham, Ala., Veterans Affairs Medical Center and the University of Alabama-Birmingham, published in the Journal of General Internal Medicine, finds that clinical techniques and care processes imported from home-based hospice professionals improved outcomes for hospitalized patients approaching the end of their lives.¹

The project, conducted in six VA medical centers, employed a multi-modal strategy for improving end-of-life care processes, with staff training for all hospital providers in how to identify actively dying patients and then communicate this information to their families. Best clinical practices, supported by electronic order sets and paper-based educational materials, were implemented. Patients also were encouraged to eat what—and when—they wanted, to sit up in bed, and to receive family visitors at all hours.

“I started the project years ago, when I noticed that patients on hospice care at home often seemed more comfortable, while if I brought them into the hospital, they sometimes got worse,” says lead author F. Amos Bailey, MD. “We went out to the home to observe what the hospice nurses were doing and then came back to the hospital to write order sets to reflect that practice.”

Key quality endpoints included:

• Rates of orders for opioid pain medications;
• Anti-psychotic medications and scopolamine for death rattle;
• Completion of advance directives; and
• Consultations for palliative care and pastoral care.

Patients were more likely to have their pain relieved and symptoms addressed, according to chart reviews of 6,066 patients who died before or after the intervention was launched.

“All of the processes we measured moved in the direction of increased comfort,” Dr. Bailey says.

This is the first study to show that palliative care techniques developed in the home setting can have an impact on end-of-life care. That’s important, he adds, because most patients die in hospitals or nursing homes.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life’s end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
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3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.