Background: End-of-life care in the acute care inpatient setting is often not initiated until very late in the dying process and may be related to inadequate early recognition of dying patients as well as difficulty transitioning from disease-modifying treatments to palliative measures. Additional barriers exist, including lack of familiarity of hospital staff with initiation and implementation of hospice care. Education about end-of-life care and introduction of a physician-led palliative care team available for consultation within acute care hospitals may help promote better recognition of the dying patient by staff and allow for a “good death.”
Methods: A single hospital within the Veterans Affairs (VA) medical system (Birmingham, Ala., VA Medical Center) was chosen as a pilot center for initiation of a physician-led Inpatient Comfort Care Program (ICCP). The study was framed as a “before-after intervention trial” and analyzed all inpatient deaths identified by the Computerized Patient Recognition System during a six-month period before and substantially after the introduction of the ICCP. A structured chart abstraction tool was used and data was obtained from the last seven days of hospitalization analyzing variables associated with recognition of the dying patient and initiation of palliative care. Education of hospital staff on both hospice care and case identification was initiated during the intervention phase of the study. Additionally, a flexible comfort care order set was introduced.
Results: Two hundred and three veterans were identified (98% men, average age 68) and no significant differences in clinical characteristics were noted between the two groups, pre-intervention and post-intervention. Post-intervention, 59.3% of patients had formal palliative care consultation. Significant findings (P<0.01) following implementation of ICCP were increased documentation of end-of-life symptoms, increased documentation of care plans, increased utilization of opioids (57.1% to 87.2%), increased initiation of do-not-resuscitate orders (61.9% to 85.1%) with a concurrent decrease in cardiopulmonary resuscitation at death (34.4% to 15.4%), and a surprising increase in restraint use (6.0% to 22.6%).
Discussion: Data on hospice care patients indicate that 10% to 30% die in an acute care hospital, identifying a need for increased education and training in palliative medicine. This study demonstrates the positive outcomes of implementation of an inpatient palliative care service both for heightened awareness of identifying the dying patient as well as initiation of end-of-life care. The increased use of opioid medications is an important marker given that many patients experience pain and dyspnea at the end of life. This study is limited by its single site and further validation at other centers implementing similar protocols and assessing similar outcomes is needed. While this intervention had important clinical benefits, additional studies examining the cost implications of this system would be helpful.
Education alone has not been shown to be entirely effective in creating change. This single-site implementation of a palliative care consultation service successfully integrated an education program with on-site consultants. Distributing pocket cards with clinical findings identifying the dying patient aided in recognition of those patients and pre-printed order sets facilitated initiation of end-of-life care. The intervention initiated is possible for many medical centers and promotes an environment allowing for a “good death” for dying patients.
Computers, Doctors, and Errors
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203
For physicians, computerized physician order entry (CPOE) has become an important topic of discussion as many hospitals and health systems embark on the complex and lengthy process of implementing new enterprise clinical systems. Though there are undoubtedly benefits to such systems, practicing clinicians are apt to remain skeptical of the grandiose pictures the more vocal advocates of CPOE may paint. This is not to say that the promises of CPOE are empty; to the contrary, there have been substantial successes, notably in the realm of medication error prevention.