Comfort Care Order Research Articles

“But I Can’t Let Him Starve!” A Comprehensive Palliative Approach to the Assessment and Management of Anorexia (TH326)

List common concerns and complications that occur using these order sets related to rapid titration of infusions. Describe an updated, evidence-based comfort care order set for withdrawal of life sustaining therapies including provider decision tools, treatment algorithms, electronic ordering design and educational dissemination. Pain, dyspnea, and other symptoms are common in lifelimiting illness, particularly in the last weeks of life. Uncontrolled symptoms at the end of life cause distress and compromise quality of life for patients and families. Clinicians also experience distress while caring for these patients. Similar to previously published standardized approaches, our old comfort care order sets were based on historical protocols for sedation and analgesia, which allowed for frequent increases in intravenous opioid continuous infusions to manage symptoms. Clinically, we have seen rapidly increasing opioid doses cause toxicity, discomfort, and moral distress. We have also seen wide variability in practice in the application of these order sets among providers and nurses. A 2013 Cochrane Review recommended that institutions audit their end-of-life pathways, citing a lack of new studies and safety concerns with current pathways. For these reasons, we sought to revise our comfort care order set with a goal to provide better symptom management for patients receiving comfortfocused care at the endof life and to providemore guidance for clinicians involved in treating these symptoms. We will describe the historical development and current literatureof comfort careorder sets to illustrate common challenges and concerns with their use. We will focus on use of opioids and benzodiazepines for symptom management, ventilator withdrawal, and education for providers and nurses. We will then present key revisions we havemade toour comfort careorder set basedon theupdated evidence, clinical practice, and feedback from colleagues. These key revisions include educational material within the order set, such as algorithms and anopioiddecision tree. Participantswill apply these tools topatient scenarios, provide feedback, andparticipate in a large group discussion. We will also share preliminary results of provider and nursing surveys on our old and revised comfort care order sets.

A New Generation of Comfort Care Order Sets: From Drips to Boluses and Beyond (TH325)

A New Generation of Comfort Care Order Sets: From Drips to Boluses and Beyond (TH325)

Using a symptom observation chart for dying patients: Review of a service improvement tool.

57 Background: In July 2014, following judicial review, the Liverpool Care Pathway for Dying Patients was withdrawn from the UK. An individualised approach to care for dying patients was advised, laid out in “One chance to get it right”. To support this, a symptom observation chart was developed at BSUH, a UK teaching hospital with cancer centre. At the point where a patient is diagnosed as dying, this innovative tool replaces vital signs assessment tools and facilitates regular and rigorous assessment of symptoms. Additionally, it aims to improve communication between healthcare professionals (HCPs), by showing trends in symptoms over time, and to trigger urgent physician review if optimal comfort is not achieved. It has scoring and escalation prompts, similar to early warning score charts, using a red-amber-green system. Methods: 8 months after introduction, a self-completed questionnaire was distributed to HCPs. Questions related to demographic data, opinion on the chart using a 4-point Likert scale and a qualitative component. Results: 135 adequately completed questionnaires (of 150) were returned by ward nurses (61%), physicians (30%), nursing assistants (7%) and palliative care specialist nurses (3%). The majority "agreed" or “strongly agreed” that the chart was user-friendly (97%); not time consuming (98%); facilitated communication between staff of the multidisciplinary team (87%); prompted earlier intervention from physicians (83%); was useful to indicate poorly controlled symptoms (96%); had improved the symptom assessment of dying patients (91%); and had contributed to improvements in the overall care of dying patients (87%). Additionally, 86% of nurses felt the chart helped them know when to request an urgent physician review to optimise comfort. Only 51% felt they had received enough training in using the chart. These findings were also reflected in free text responses. Conclusions: The vast majority of HCPs found the chart easy to use and felt it improved overall care of dying patients. Therefore, the chart may be a valuable addition to Comfort Care Order Sets. Prospective research is warranted to further assess the chart. The chart will be visually presented. It may be adapted and reproduced with permission.

Abstract NS22: Palliative Care in the Stroke Patient

Background and Purpose: Palliative and end of life care are gaining importance in the healthcare environment. Palliative care and hospice may be underutilized in this population. Evaluation of current process will determine opportunities for improvement. Methods and Results: Retrospective review of patients admitted over one year with the diagnosis of acute ischemic stroke (AIS) and hemorrhagic stroke was completed, assessing 575 records. This population included 491 AIS and 84 hemorrhages. Eighty-one AIS patients received t-PA. Discharge status distribution included: 269 to home; 114 to acute rehabilitation; 123 to skilled nursing facilities (SNF); 29 to hospice; and 42 died. Fifty-five patients had comfort care orders prior to discharge: 32 by hospital day two, 23 by hospital day three or later. AIS patients with comfort care orders had an average NIHSS of 17; hemorrhagic stroke patients had an average GCS of 5. Patients with comfort care orders were an average age of 72 years with equal distribution (AIS = 27; hemorrhage = 28) and gender (25 male, 30 female); majority were Caucasian (3 African American, 1 Latino, 1 Asian). Twenty patients with similar characteristics were discharged to SNF with no discussion of palliative care or hospice. A review of records revealed provider disagreement for long-term prognosis as a significant barrier to patient/family decisions regarding end of life choices, or supporting choices made by patients/family opting for palliative care. Conclusions: Based on these data, a palliative care nurse joined the stroke team, and the stroke coordinator joined the palliative care committee to assist in these conversations. Palliative care training for providers is on-going in the acute care setting, while outpatient providers are being engaged in utilizing The Iowa Physician Order for Scope of Treatment (IPOST).This document was designed to promote community care coordination and advanced care planning, in order to provide seamless communication and execution of individual care choices across the healthcare continuum. As these strategies are implemented, an increase in end of life planning is anticipated.

Factors associated with two different protocols of do-not-resuscitate orders in a medical ICU*.

The State of Ohio in the United States has the legislation for two different protocols of do-not-resuscitate orders. The objective of this study was to examine the clinical/demographic factors and outcomes associated with the two different do-not-resuscitate orders. Data were concurrently and retrospectively collected from August 2002 to December 2005. The clinical/demographic factors of do-not-resuscitate patients were compared with those of non-do-not-resuscitate patients, and the clinical/demographic factors of do-not-resuscitate comfort care-arrest patients were compared with those of do-not-resuscitate comfort care patients. An ICU in a university-affiliated hospital located at Northeast Ohio in the United States. A sample of 2,440 patients was collected: 389 patients were do-not-resuscitate; and 2,051 patients were non-do-not-resuscitate. Among the 389 do-not-resuscitate patients, 194 were do-not-resuscitate comfort care-arrest patients and 91 were do-not-resuscitate comfort care patients. None. The factors associated with do-not-resuscitate were older age, race and ethnicity with white race, more severe clinical illness at admission to the ICU, and longer stay before admission to the ICU. Comparing do-not-resuscitate comfort care-arrest patients with do-not-resuscitate comfort care patients, those with more severe clinical illness, longer ICU stay before making a do-not-resuscitate decision, and being cared for by only one intensivist during ICU stay were significantly associated with do-not-resuscitate comfort care decisions. For 149 do-not-resuscitate patients who eventually survived to hospital discharge and 86 do-not-resuscitate patients who eventually did not, only eight (5.4%) and 23 (26.7%) had the order written within 48 hours before the end of ICU stay, respectively. Our study showed that some clinical/demographic factors predicted do-not-resuscitate comfort care orders. This study also suggested that Ohio's Do-Not-Resuscitate Law, clearly indicating two different protocols of do-not-resuscitate orders, facilitated early do-not-resuscitate decision.

Palliative Care Intervention for Choice and Use of Opioids in the Last Hours of Life

The purpose of this study was to evaluate the effects of a multicomponent palliative care intervention on choice and use of opioid pain medications for symptom control for patients dying in an acute care inpatient setting. A preintervention/postintervention trial was conducted between 2001 and 2003. Participants were physician, nursing, and ancillary staff of inpatient services of an urban, tertiary care Veterans Affairs (VA) Medical Center. The intervention included staff education to better identify actively dying patients and a Comfort Care Order Set to guide care in the last hours of life. Data abstracted from computerized medical records of 191 veterans who died during a 6-month period before (N=98) and after (N=93) the intervention were used to examine changes in choice and amount of medication administered in the last 3 days of life. Findings show a significant increase in orders specifically for morphine from 47.4% to 81.7% (p<.001). Orders for hydromorphone or oxycodone did not increase significantly, and no patients had orders for meperidine or codeine. There was an increase in the administration of opioids from 16.7% to 73.0% of patients (p<.001). The amount of opioid administered (in oral morphine equivalents) increased from 31.9 mg/72 hours preintervention to 52.9 mg/72 hours postintervention (p=.12). The results indicate that the availability of morphine as a preferred opioid and the number of patients who received opioid medication during the last 3 days of life increased after introduction of the inpatient palliative care program.

Clinical and Economic Impact of Palliative Care Consultation

Palliative care consultation is the most common model of hospital-based services in the United States, but few studies examine the impact of this model. In a prospective study, we describe the impact of palliative care consultation on symptoms, treatment, and hospital costs. Patients receiving interdisciplinary palliative care consultations from 2002 to 2004 were approached for enrollment; 304 of 395 (77%) patients participated. Measures included diagnosis, treatment decisions, and symptom scores. To test impact on costs, a one-year subset of cases with lengths of stay >4 days ( n = 104) was compared to all available controls ( n = 1,813) matched on the 3M™ All Patients Refined Diagnosis Related Group, Version 20, and mortality risk scores. Half of the patients were younger than 65 years, 28% were African American, and 61% had cancer. Median Palliative Performance score was 20 (range, 10–100). Recommendations were implemented in 88% of cases; new “do not resuscitate/do not intubate” orders were written for 34% of patients, new comfort care orders for 44%, and 27% were referred for hospice care. Symptom scores improved from Day 1 to Day 3, with greatest improvement in pain (2.6–1.4, P < 0.001). Compared to matched controls without palliative care consultation, palliative care cases had lower cost per day ($897 vs. $1004, P = 0.03). Per diem variable costs were 10.7% less for all palliative care cases and 20.5% less for those with >50% hospital days with palliative care consultation. Palliative care consultation is followed by decisions to forego costly treatment and improved symptom scores, and earlier palliative care intervention results in greater cost-savings.

Improving Processes of Hospital Care During the Last Hours of Life

Known for excellence in care in the last days and hours of life, hospice programs can help individuals have a "good death" and lead to higher family satisfaction with quality of care. Our objective was to evaluate the effectiveness of a multicomponent palliative care intervention based on the best practices of home hospice and designed to improve the quality of care provided for patients dying in an acute care inpatient setting. This study was a before-after intervention trial conducted between 2001 and 2003. Participants included physician, nursing, and ancillary staff on inpatient services of an urban, tertiary care Veterans Affairs medical center. The palliative care intervention included staff education and support to identify patients who were actively dying and implement care plans guided by a comfort care order set template for the last days or hours of life. Data abstracted from computerized medical records of 203 veterans who died during a 6-month period before (n = 108) and after (n = 95) intervention were used to determine the impact of intervention on symptom documentation and 5 process of care indicators. There was a significant increase in the mean (SD) number of symptoms documented from 1.7 (2.1) to 4.4 (2.7) (P<.001), and the number of care plans increased from 0.4 (0.9) to 2.7 (2.3) (P<.001). Opioid medication availability increased from 57.1% to 83.2% (P<.001), and do-not-resuscitate orders increased from 61.9% to 85.1% (P<.001). There were nonsignificant changes in the proportion of deaths that occurred in intensive care units (P = .17) and in the use of nasogastric tubes (P = .40), and there was a significant increase in the use of restraints (P<.001). Our results indicate that end-of-life care improved after the introduction of the palliative care program.

Emergency department management and resource utilization in patients with Do-Not-Resuscitate orders

Study objectives: The advent of the do-not-resuscitate (DNR) clause has brought with it comfort, anxiety, and sometimes anguish for patients, families, and health providers. To date, there is no information in the emergency literature describing practice patterns and treatment of patients with orders. The objective of this study is to determine whether there is a difference in the emergency department (ED) treatment or cost of in patients with DNR comfort care orders compared with patients with DNR general medical care or patients without orders. Methods: A retrospective, matched pair, case-control design was used. Medical records for all patients residing in extended facilities evaluated in the ED in 2002 were reviewed. After confirmation of DNR comfort care status, variables of interest were abstracted. Controls were matched on ED International Classification of Diseases, Ninth Revision diagnosis code, sex, age, and clinical acuity. Results: Review of 3,176 records resulted in 48 potential DNR–comfort cases. A total of 26 patients could be appropriately matched. There was no significant difference in the age between DNR–comfort and DNR–general medical groups (85.8 versus 81.5 years, respectively; P =.11). Sex and racial distributions were the same for both groups. As expected, an ambulance was used to transport more than 85% of patients but did not differ according to status ( P =.12). There was no difference in ordering CBC count, metabolic panel, or urinalyses ( P >.24). No difference in use of cranial or abdominal computed tomography was found ( P >.32). ED disposition and type of nursing unit on admission did not differ ( P >.61). Although the average hospital cost in DNR–comfort patients was lower ($8,323.29 versus $15,332.58), it did not reach statistical significance ( P =.10). Conclusion: In this small, single-center sample, there was no difference in the ED treatment, resource utilization, or cost of between DNR–comfort and DNR–general medical patients.