National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for quality palliative care, executive summary

Dying with dementia in long-term care

PURPOSE

To better understand the experiences and potential unmet need of persons who die in long-term care.

DESIGN AND METHODS

We conducted after-death interviews with staff who had cared for 422 decedents with dementia and 159 who were cognitively intact and received terminal care in U.S. nursing homes (NHs) or residential care-assisted living (RC-AL) settings. We conducted family caregiver interviews for 293 decedents.

RESULTS

We noted no differences between decedents with and without dementia in terms of pain, psychosocial status, family involvement, advance care planning, most life-prolonging interventions, and hospice use. Dying residents with dementia tended to die less often in a hospital, have less shortness of breath, receive more physical restraints and sedative medication, and use emergency services less frequently on the last day of life. Persons with dementia dying in RC-AL settings tended to have more skin ulcers and poorer hygiene care than nondemented persons in RC-AL settings. In comparison with persons dying with dementia in NHs, those in RC-AL settings tended to be restrained less often, have emergency services called more often on the day of death, and have family more satisfied with physician communication.

IMPLICATIONS

These results suggest that the overall quality of care for persons dying with dementia in long-term-care settings may not differ markedly from that provided to persons who are cognitively intact. Similarly, large discrepancies in the overall quality of palliative care for persons with dementia in RC-AL facilities and NHs were not identified. However, numerous specific areas for care improvement were noted.

Gap analysis of cultural and religious needs of hospitalized patients

PURPOSE

Identify patient and family needs specifically related to an in-hospital birth or death. This study aimed to perform a gap analysis between identified needs and current hospital practice, services, and resources.

METHODS

With the IRB approval, and purposive sampling using the demographics of a community hospital plus subgroups from problematic cases. Twenty-two semistructured interviews were audiotaped, and 6 lectures and 2 panel discussions were videotaped. Transcriptions were distributed to the research team and manually coded for gaps between current practices versus stated needs. Group process was used to form consensus regarding findings.

PARTICIPANTS

The following subgroups were targeted: Muslim, Baha'i, Catholic, Protestant, Jewish, Buddhist, Mormon, Jehovah's Witness, Latino, Filipino, Chinese, African American.

RESULTS

Gaps in available resources, such as prayer books, rugs, and compasses, were identified. Knowledge gaps included many issues such as the Muslim preference for decreasing sedatives at end of life to be able to recite the sacred prayer while dying. Practice issues such as respecting plain-clothed clergy, the impact of "rule-orientation" on family needs, and the universal need to call clergy early were identified.

Easing of Suffering in Children With Cancer at the End of Life: Is Care Changing?

Purpose

In the past decade studies have documented substantial suffering among children dying of cancer, prompting national attention on the quality of end-of-life care and the development of a palliative care service in our institutions. We sought to determine whether national and local efforts have led to changes in patterns of care, advanced care planning, and symptom control among children with cancer at the end of life.

Methods

Retrospective cohort study from a US tertiary level pediatric institution. Parent survey and chart review data from 119 children who died between 1997 and 2004 (follow-up cohort) were compared with 102 children who died between 1990 and 1997 (baseline cohort).

Results

In the follow-up cohort, hospice discussions occurred more often (76% v 54%; adjusted risk difference [RD], 22%; P < .001) and earlier (adjusted geometric mean 52 days v 28 days before death; P = .002) compared with the baseline cohort. Do-not-resuscitate orders were also documented earlier (18 v 12 days; P = .031). Deaths in the intensive care unit or other hospitals decreased significantly (RD, 16%; P = .024). Parents reported less child suffering from pain (RD, 19%; P = .018) and dyspnea (RD, 21%; P = .020). A larger proportion of parents felt more prepared during the child's last month of life (RD, 29%; P < .001) and at the time of death (RD, 24%; P = .002).

Conclusion

Children dying of cancer are currently receiving care that is more consistent with optimal palliative care and according to parents, are experiencing less suffering. With ongoing growth of the field of hospice and palliative medicine, further advancements are likely.

Psychosocial aspects of pulmonary hypertension: a review

Pulmonary arterial hypertension (PAH) is characterized by progressive and sustained elevation of pulmonary-artery pressure, which ultimately leads to right-ventricular failure and death. The diagnosis carries with it an uncertain and historically very bleak prognosis. Although new oral and chronic parenteral (intravenous and subcutaneous) treatments have had a significant positive medical impact on the physical functioning of individuals with PAH, patients often struggle with new short- and long-term psychosocial challenges. The purpose of the current article is to 1) provide a brief review of PAH and its treatment; 2) summarize the limited literature examining the psychosocial adjustment of those with a PAH diagnosis; and 3) provide pertinent information extrapolated from the larger literature on chronic illness that might inform us on the psychosocial challenges faced by the patient diagnosed with PAH.

Collaborative communication in pediatric palliative care: a foundation for problem-solving and decision-making

In an ideal world, all of us - patients, parents, family members, nurses, physicians, social workers, therapists, pastoral care workers, and others - would always work together in a collaborative manner to provide the best care possible. This article bases the framework for this ideal upon studies of communication between patients, families, and clinicians, as well as more general works on communication, collaboration, decision-making, mediation, and ethics, and is comprised of four parts: what is meant by collaborative communication; key concepts that influence how we frame the situations that children with life-threatening conditions confront and how these frameworks shape the care we provide; general topics that are important to the task of collaborative communication, specifically how we use heuristics when we set about to solve complicated problems; and three common tasks of collaborative communication, offering practical advice for patient care.

Palliative Care Consultation, Quality-of-Life Measurements, and Bereavement for End-of-Life Care in Patients With Lung Cancer

OBJECTIVE

To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer.

METHODS

To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients.

RESULTS

Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death.

CONCLUSION

Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Dignified death for severely impaired infants: beyond the best-interest standard

The Baby Doe rules, a set of federal regulations on the treatment of extremely ill infants, went into effect in 1985. Some scholars have argued that these rules are inappropriate given that they fail to pay attention to the patient's suffering. Instead, researchers suggest that, when dealing with a severely impaired infant, the best-interest standard be used. Other ethicists have found the best-interest standard also insufficient, deeming it to be supported by weak arguments rooted on the beholder's beliefs. In this article, alternative viewpoints that might be used to complement the best-interest standard and help support the rights of severely impaired infants to a natural and dignified death are reviewed. The use of palliative instead of intensive care for severely impaired newborns is also considered.

Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback

OBJECTIVE

To develop a practical set of measures for routine monitoring, performance feedback, and improvement in the quality of palliative care in the intensive care unit (ICU).

DESIGN

Use of an interdisciplinary iterative process to create a prototype "bundle" of indicators within previously established domains of ICU palliative care quality; operationalization of indicators as specified measures; and pilot implementation to evaluate feasibility and baseline ICU performance.

SETTING

The national Transformation of the Intensive Care Unit program developed in the United States by VHA Inc.

PATIENTS

Critically ill patients in ICUs for 1, > 3, and > 5 days.

MEASUREMENTS AND MAIN RESULTS

Palliative care processes including identification of patient preferences and decision making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management, as documented in medical records. Application is triggered by specified lengths of ICU stay. Pilot testing in 19 ICUs (review of > 100 patients' records) documented feasibility, while revealing opportunities for quality improvement in clinician-patient/family communication and other key components of ICU palliative care.

CONCLUSIONS

The new bundle of measures is a prototype for routine measurement of the quality of palliative care in the ICU. Further investigation is needed to confirm associations between measured processes and outcomes of importance to patients and families, as well as other aspects of validity.

Getting services right for those sick enough to die

A model based on common trajectories of illness and associated care needs would improve the care of people with serious illness in the last phase of life, say Sydney Dy and Joanne Lynn

Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005

OBJECTIVE

To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU.

PARTICIPANTS

A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units.

EVIDENCE

The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion.

CONSENSUS PROCESS

The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal.

CONCLUSIONS

More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Measuring the quality of dying and death: methodological considerations and recent findings

PURPOSE OF REVIEW

While the need to improve the quality of dying and death in critical settings has been well accepted, there is less agreement on which measures and criteria are best used to assess it. In this article, we present methodological considerations and recent findings that pertain to the measurement of the quality of dying and death.

RECENT FINDINGS

Research evaluating the quality of dying and death employs measures based on professionally determined criteria as well as measures relying on patient and family-centered standards. Professionally determined measures include assessments of resource consumption (e.g., length of stay, costs of care, technology utilization) and processes of care (e.g., do-not-resuscitate orders, family conferences). Studies of interventions designed to improve end-of-life care have shown positive changes in these outcomes. Patient and family-centered measures (e.g., quality of dying and death questionnaires, quality of end-of-life care questionnaires) have been used less often in intervention studies but, in descriptive studies, have shown important associations with factors related to a 'good death'.

SUMMARY

These findings suggest a need to integrate both types of measures in research on the quality of end-of-life experiences. This integration, with attention to important methodological issues, may represent a significant step toward improving patients' experiences at the end-of-life.

The physician's role in the assessment and treatment of spiritual distress at the end of life

OBJECTIVE

Patients at the end of their life typically endure physical, emotional, interpersonal, and spiritual challenges. Although physicians assume a clearly defined role in approaching the physical aspects of terminal illness, the responsibility for helping their patients' spiritual adaptation is also important.

METHODS

This article (1) describes the terms and definitions that have clinical utility in assessing the spiritual needs of dying patients, (2) reviews the justifications that support physicians assuming an active role in addressing the spiritual needs of their patients, and (3) reviews clinical tools that provide physicians with a structured approach to the assessment and treatment of spiritual distress.

RESULTS

This review suggests that physicians can and should be equipped to play a key role in relieving suffering at the end of life.

SIGNIFICANCE OF RESULTS

Physicians can help their patients achieve a sense of completed purpose and peace.

Integrating palliative and neurological critical care

The goal of palliative care is to provide the alleviation or reduction of suffering and the support for the best possible quality of life for patients regardless of the stage of the disease. Palliative care can be provided in any patient care setting, including intensive care units. Death in intensive care units is a common occurrence, with literature suggesting that approximately 20% of deaths in the United States occur after a stay in the intensive care unit. Other studies suggest that approximately half of all chronically ill patients who die in a hospital receive care in the intensive care unit within 3 days of their deaths. Critical care nurses who work in neurological intensive care units are at the forefront of integrating palliative and critical care.

The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]

BACKGROUND

The Karnofsky Performance Status (KPS) is a gold standard scale. The Thorne-modified KPS (TKPS) focuses on community-based care and has been shown to be more relevant to palliative care settings than the original KPS. The Australia-modified KPS (AKPS) blends KPS and TKPS to accommodate any setting of care.

METHODS

Performance status was measured using all three scales for palliative care patients enrolled in a randomized controlled trial in South Australia. Care occurred in a range of settings. Survival was defined from enrollment to death.

RESULTS

Ratings were collected at 1600 timepoints for 306 participants. The median score on all scales was 60. KPS and AKPS agreed in 87% of ratings; 79% of disagreements occurred within 1 level on the 11-level scales. KPS and TKPS agreed in 76% of ratings; 85% of disagreements occurred within one level. AKPS and TKPS agreed in 85% of ratings; 87% of disagreements were within one level. Strongest agreement occurred at the highest levels (70-90), with greatest disagreement at lower levels (< or =40). Kappa coefficients for agreement were KPS-TKPS 0.71, KPS-AKPS 0.84, and AKPS-TKPS 0.82 (all p < 0.001). Spearman correlations with survival were KPS 0.26, TKPS 0.27 and AKPS 0.26 (all p < 0.001). AKPS was most predictive of survival at the lower range of the scale. All had longitudinal test-retest validity. Face validity was greatest for the AKPS.

CONCLUSION

The AKPS is a useful modification of the KPS that is more appropriate for clinical settings that include multiple venues of care such as palliative care.