Intervention to improve care at life's end in inpatient settings: the BEACON trial

Assessing for differences in opioid administration during inpatient end-of-life care for patients with limited English proficiency

BACKGROUND

Patients with limited English proficiency (LEP) may have worse health outcomes and differences in processes of care. Language status may particularly affect situations that depend on communication, such as symptom management or end-of-life (EOL) care.

OBJECTIVE

The objective of this study was to assess whether opioid prescribing and administration differs by English proficiency (EP) status among hospitalized patients receiving EOL care.

METHODS

This single-center retrospective study identified all adult patients receiving "comfort care" on the general medicine service from January 2013 to September 2021. We assessed for differences in the quantity of opioids administered (measured by oral morphine equivalents [OME]) by patient LEP status using multivariable linear regression, controlling for other patient and medical factors.

RESULTS

We identified 2652 patients receiving comfort care at our institution during the time period, of whom 1813 (68%) died during the hospitalization. There were no significant differences by LEP status in terms of mean OME per day (LEP received 30.8 fewer OME compared to EP, p = .91) or in the final 24 h before discharge (LEP received 61.7 more OME compared to EP, p = .80).

CONCLUSION

LEP was not associated with differences in the amount of opioids received for patients whose EOL management involved standardized order sets for symptom management at our hospital.

Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment

Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

BACKGROUND

Racial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end-of-life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution.

METHODS

We launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time-series analyses to measure the differential impact of the intervention across race, ethnicity, and language.

KEY RESULTS

A total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non-Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non-Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant.

CONCLUSIONS

An intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.

Clinical effects of hydration, supplementary vitamins, and trace elements during end-of-life care for cancer patients

INTRODUCTION

current data regarding the decision on rehydration of patients with terminal-stage cancer remain controversial.

OBJECTIVE

the present study was to evaluate the effect of intravenous hydration and supplementary vitamins and trace elements on clinical symptoms and biochemical parameters in palliative cancer patients.

METHODS

a randomized clinical trial including 72 palliative cancer patients aged 18 years and older was performed at the National Cancer Institute in Mexico. Patients were divided into two groups: intervention and control, both receiving intravenous saline solution weekly for 4 weeks, but the former was also supplemented with vitamins and trace elements. Symptoms were assessed at baseline and 4 weeks after with the Edmonton Symptom Assessment Scale. Same measurements applied to biochemical parameters.

RESULTS

the mean age of the patients was 58.75 years. The most frequent cancer diagnoses were gastrointestinal (32 %). In the between-groups analysis significant improvements were found for the intervention group in anorexia (p = 0.024), pain (p = 0.030), chloride (p = 0.043), phosphorus (p = 0.001), potassium (p = 0.006), and total proteins (< 0.0001).

CONCLUSION

we highlight the improvement in the control of most symptoms and some biochemical parameters in the intervention group receiving vitamins and oligoelements along with intravenous hydration. Further studies are needed.

Comparing Adherence with Best Practices in End-of-Life Care After Implementing the End-of-Life Order Set: A Quality Improvement Project in an Ottawa Academic Hospital

Background

Physicians in acute care require tools to assist them in transitioning patients from a "life prolonging" approach to "end-of-life care," and standardized order sets can be a useful strategy. The end-of-life order set (EOLOS) was developed and implemented in the medical wards of a community academic hospital.

Objective

To compare adherence with best practices in end-of-life care after implementing the EOLOS.

Methods

We conducted a retrospective chart review of admitted patients with expected deaths in the year preceding EOLOS implementation ("before EOLOS" group), and in the 12 to 24 months following EOLOS implementation ("after EOLOS" group).

Results

A total of 295 charts were included: 139 (47%) in the "before EOLOS" group and 156 (53%) in the "after EOLOS" group, of which 117/156 charts (75%) had a completed EOLOS. The "after EOLOS" group demonstrated more "do not resuscitate" orders and more written communication to team members about comfort goals of care. There was a decrease in nonbeneficial interventions in the last 24 hours of life in the "after EOLOS" group: high-flow oxygen, intravenous antibiotics, and deep vein thrombosis/venous thromboembolism prophylaxis. The "after EOLOS" group demonstrated increased prescription of all common end-of-life medications, except for opioids, which had a high preexisting rate of prescription. Patients in the "after EOLOS" group showed a higher rate of spiritual care and palliative care consult team consultation.

Conclusion

Findings support standardized order sets as a good framework allowing generalist hospital staff to improve adherence to established palliative care principles and improve end-of-life care of hospital inpatients.

The meaning of comfort measures only order sets for hospital-based palliative care providers

Purpose

Comfort Measures Only (CMO) is a label commonly used in the USA that guides the care of a hospitalized patient who is likely to die. The CMO label has unclear and inconsistent meaning, calling to question the experiences and practices of hospital-basedalliative care providers. The purpose of this study was to understand the meaning of CMO as experienced by hospital-based palliative care providers.

Methods

Using hermeneutic phenomenological research, we investigated eight palliative care experts’ common experiences and shared practices of using CMO order sets in their hospital work settings. Data were collected through individual face-to-face interviews, and were analysed by an interpretive team.

Results

Four related themes and one constitutive pattern of “Dealing with Dying” reflect the meaning of comfort-measures-only practices. The themes are: comfort care as morphine drip; enacting a traditional binary pattern of care: all or nothing; supporting patient and family at end of life vs. CMO; and evolving culture—a better way to care for the dying.

Conclusion

Palliative care providers and non-palliative clinicians understood and practiced end of life care in sharply different ways with dying in hospital settings, raising new questions that analyse, modify and extend extant knowledge.

Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention

CONTEXT

Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care.

OBJECTIVES

To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy.

METHODS

The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes.

RESULTS

Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001).

CONCLUSIONS

This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.

A Comfort Measures Only Checklist for Critical Care Providers: Impact on Satisfaction and Symptom Management

PURPOSE

This quality improvement project created a guide for critical care providers transitioning patients to comfort measures only encouraging communication, collaboration, and shared decision making; ensuring management of patients' end-of-life symptoms and needs; and enhancing provider satisfaction by improving structure and consistency when transitioning patients.

DESCRIPTION OF THE PROJECT

Interviews conducted with staff in intensive care units revealed opportunities to improve structure and processes of transitioning patients at the end of life. A subcommittee of experts designed a checklist to facilitate interdisciplinary conversations. Impact on provider satisfaction and symptom management was assessed. Presurveys circulated used a Research Electronic Data Capture tool. A checklist was implemented for 3 months, and then postsurveys were sent. Charts were audited to identify improvement in symptom management and compared with retrospective samples.

OUTCOMES

Clinical improvements were seen in communication (12%), collaboration (25%), shared decision making (22%), and order entry time (17%). In addition, 72% agreed the checklist improved structure and consistency; 69% reported improved communication, collaboration, and shared decision making; 61% felt it improved knowledge/understanding of patient needs; and 69% agreed it improved management of patient symptoms.

CONCLUSION

After checklist implementation, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; no improvement in patient outcomes was realized.

Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial

BACKGROUND

There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings.

OBJECTIVE

To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs).

DESIGN

Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites.

PARTICIPANTS

One hundred thirty-two providers from PCCTs at 47 VAMCs.

INTERVENTIONS

Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers.

MAIN MEASUREMENTS

Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates.

KEY RESULTS

Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement.

CONCLUSION

Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02383173.

Pharmacological treatment in the dying geriatric patient: describing use and dosage of opioids in the acute geriatric wards and palliative care units of three hospitals

PURPOSE

The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available.

METHODS

In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected.

RESULTS

Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7-51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1-53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not.

CONCLUSIONS

This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary.

Macy Catheter: Integration and Evaluation in a Hospice Setting to Provide Symptom Relief During End-of-Life Care

Provision of high-quality end-of-life care in a cost-effective work environment is the aim of all hospice organizations. This opportunity can be negatively affected when there is a limited supply of parenteral narcotics or administration routes are either not functional or fail to control symptoms. To combat these challenges, including a shortage of available parenteral narcotics, staff at a hospice organization adopted the use of a rectal catheter to deliver oral medications that were readily available. The implementation of a rectal catheter resulted in better control of symptoms, fewer titrations, and improvement in pain control and/or symptom management needs during end-of-life care management.

Patterns of benzodiazepine administration and prescribing to older adults in U.S. emergency departments

OBJECTIVES

Benzodiazepine use in older adults is associated with adverse effects including delirium, mechanical falls, fractures, and memory disturbances. In this study we examine the overall utilization of benzodiazepines in the older adult population in U.S. EDs.

METHODS

Data were compiled from the National Hospital Ambulatory Medical Care Survey 2005-2015. Variables were created to identify all patients over 60 years of age who had and had not been administered benzodiazepines. Bivariate statistical tests were utilized to examine patient demographics, hospital course events and ED/hospital resource allocation and compare older adults administered (in the ED) and prescribed (from the ED) benzodiazepines to those not receiving these agents.

RESULTS

Between 2005 and 2015 approximately 280 million adults over 60 years of age were seen in EDs throughout the U.S. Overall, benzodiazepines were administered in the ED (only) during 8.5 million visits, and prescribed as a prescription (only) during over 1.3 million visits, with the rate increasing from 2.7% in 2005 to 3.5% in 2015 for benzodiazepines were administered in the ED (only). Overall 42.1% (95% CI 38.8-45.2, p < 0.001) of older adults administered benzodiazepines in the ED were subsequently admitted to the hospital. Rates of co-administration and co-prescription of opioid analgesics were high at 19.0% (95% CI 7.3-19.7) and 17.0% (95% CI 7.9-17.4) for those administered benzodiazepines in the ED, and 21.8% (95% CI 16.3-28.5) and 34.5% (95% CI 27.7-42.0) amongst those prescribed benzodiazepines at discharge. In both cases, these groups were no less likely to be administered opioids in the ED than those not receiving benzodiazepines. A total of 1.1% (95% CI 0.69-1.7, p < 0.001) of older adults administered (in the ED) benzodiazepines were diagnosed with delirium in the ED, compared to 0.0004% who were not (95% CI 0.0038-0.0052).

CONCLUSION

Despite the documented risks associated with the utilization of benzodiazepines in older adults, the rate of use in EDs continues to increase. Older adults administered benzodiazepines in the ED were more likely to be admitted to the hospital than those not receiving these agents. Despite the risks associated with co-prescription of benzodiazepines with opioids, those receiving these agents were no less likely to be administered opioids than those who did not. Older adults administered benzodiazepines in the ED were substantially more likely to be diagnosed with delirium in the ED.

Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness

Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Evaluating the Pharmacological Management of Terminal Delirium in Imminently Dying Patients With and Without the Comfort Measure Order Set

Terminal delirium is a distressing irreversible process that occurs frequently in the dying phase, often misdiagnosed and undertreated. A previous study in our organization revealed that terminal delirium was a poorly managed symptom at end of life. Pharmacological options are available in an existing order set to manage this symptom. The management plans of 41 patients identified as having terminal delirium were further evaluated. Elements extracted included medications prescribed to manage terminal delirium, whether medication changes occurred, and whether they were administered and effective. Patients with the order set were more comfortable as compared with the group without. Both groups had several changes made by the palliative care team. Nurses did not administer prescribed as-needed medication to more than one-third of patients. Modifications will be made to the existing order set, and additional education for staff will be organized.

A systematic review of interventions aiming to improve communication of prognosis to adult patients

OBJECTIVE

Our objective was to describe interventions that aim to improve communication of prognosis to adult patients and to summarize the effect of interventions.

METHODS

We included randomized controlled trials of interventions that included prognosis delivery. We excluded studies of decision aids. Our analysis was a narrative synthesis of interventions and outcomes.

RESULTS

Our search identified 1151 unique records. After screening, and full text review we included 21 reports from 17 RCTs. Only 2 studies used a prediction model to generate prognostic estimates. Four studies used education, ten used patient mediated interventions, and 2 used coordination of care. In some studies education that includes prognosis improves patient reported outcomes, communication and treatment decisions, patient mediated interventions can increase the number of questions patients ask about prognosis. Coordination of care may improve satisfaction.

CONCLUSIONS

Education for clinicians that includes teaching about how to communicate prognosis may improve patient reported outcomes. Patient mediated interventions can increase the number of prognosis related questions asked by patients.

PRACTICE IMPLICATIONS

Communication skills training that includes training on delivering prognosis may improve communication and patient reported outcomes, but the evidence is uncertain. Giving patients question prompt lists can help them ask more prognosis related questions.

The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization.

OBJECTIVES

To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration.

DESIGN

Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center.

SUBJECTS

Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011.

MAIN MEASURES

Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life.

KEY RESULTS

Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138).

CONCLUSIONS

PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients.

TRIAL REGISTRATION

NCT00234286.

Association between palliative care and the rate of advanced care planning: A systematic review

OBJECTIVE

Advanced care planning (ACP) is central to patients' dignity and autonomy; however, in many countries it is underutilized. Studies that tested the effects of palliative care (PC) often included the rate of documented ACP as a secondary end point. We aimed to assess the contribution of PC to the rate of ACP among terminally ill patients by systematically reviewing relevant clinical trials.

METHOD

PUBMED and "Cochrane trials" databases were screened for clinical trials published until October 2017 that compared the addition of PC to standard treatment and that had ACP as a primary or a secondary end point. Studies were assessed for validity by three investigators using the Cochrane Collaboration tool and the ROBINS-I tool for randomized controlled trials (RCTs) and for cohort studies, respectively.

RESULTS

Twenty-six trials with 37,924 patients were included. Four were RCTs, nine were cohort studies, and 12 were cross-sectional studies. Randomized trials had the lowest risk of bias. There was a positive correlation between the addition of PC and ACP in 25 studies, among them four randomized trials.

SIGNIFICANCE OF RESULTS

In this systematic review, PC was associated with improvement in the rate of ACP. Understanding the significant effect of PC on the completion of ACP is an additional emphasis on the importance of this treatment among terminally ill patients.

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

CONTEXT

Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties.

OBJECTIVE

To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL.

METHODS

We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life.

RESULTS

Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification.

CONCLUSION

Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

Outcomes of Palliative Care Consults With Hospitalized Veterans

Families and patients receive emotional support and better care planning after palliative care consultations.

Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review

BACKGROUND

Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking.

OBJECTIVES

To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use.

DESIGN

Systematic review of articles in English, published from inception of databases to December 2017.

DATA SOURCES

PubMed, PsycINFO, EMBASE, and CINAHL.

METHODS/MEASUREMENTS

Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration's risk assessment tool.

RESULTS

Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre-post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias.

CONCLUSIONS

Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.

Validity and Reliability of the Dying Care Process and Outcome Scales Before and After Death From the Bereaved Family Members' Perspective

OBJECTIVE:

There are no instruments evaluating the processes and outcomes of dying care right before and after death. Therefore, we developed and examined the validity and reliability of 2 scales for evaluating dying care processes and outcomes before and after death.

METHODS:

A cross-sectional, anonymous questionnaire was administered to bereaved family members of patients with cancer who had died in 5 facilities. We evaluated the Dying Care Process Scale for Bereaved Family Members (DPS-B) and the Dying Care Outcome Scale for Bereaved Family Members (DOS-B) with 345 bereaved family members.

RESULTS:

A factor analysis revealed that DPS-B and DOS-B each consisted of 4 subscales. For the DPS-B, they were "symptom management," "respect for the patient's dignity before and after death," "explanation to the family," and "family care." For the DOS-B, they were "peaceful dying process for the patient," "being respected as a person before and after death," "good relationship between the patient and family," and "peaceful dying process for the family." Both DPS-B and DOS-B had sufficient convergent and discriminative validity, sufficient internal consistency (DPS-B: α = 0.91 and subscales' αs = 0.78-0.91; DOS-B: α = 0.91 and subscales' αs = 0.78-0.94), and sufficient test-retest reliability (DPS-B: intraclass correlation coefficient [ICC] of total score = 0.79 and subscales = 0.55-0.79; DOS-B: ICC of total score = 0.88 and subscales = 0.70-0.88).

SIGNIFICANCE OF RESULTS:

Both DPS-B and DOS-B are valid and reliable scales for evaluating the dying care processes and outcomes before and after death from the bereaved family members' perspectives.

Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care

In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

OBJECTIVES

To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration.

DESIGN AND METHODS

A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes.

RESULTS

Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal.

CONCLUSIONS

A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.

The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

BACKGROUND

Standardized protocols have been previously shown to be helpful in managing end-of-life (EOL) care in hospital. The comfort measures order set (CMOS), a standardized framework for assessing imminently dying patients' symptoms and needs, was implemented at a tertiary academic hospital.

OBJECTIVE

We assessed whether there were comparable differences in the care of a dying patient when the CMOS was utilized and when it was not.

METHODS

A retrospective chart review was completed on patients admitted under oncology and general internal medicine, who were referred to the inpatient palliative care team for "EOL care" between February 2015 and March 2016.

RESULTS

Of 83 patients, 56 (67%) received intiation of the CMOS and 27 (33%) did not for EOL care. There was significant involvement of spiritual care with the CMOS (66%), as compared to the group without CMOS (19%), P < .05. The use of CMOS resulted in 1.7 adjustments to symptom management per patient by palliative care, which was significantly less than the number of symptom management adjustments per patient when CMOS was not used (3.3), P < .05. However, initiating CMOS did not result in a signficant difference in patient distress around the time of death ( P = .11). Dyspnea was the most frequently identified symptom causing distress in actively dying patients.

CONCLUSIONS

Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Continuation of non-essential medications in actively dying hospitalised patients

OBJECTIVE

The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients.

METHODS

This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation's Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans.

RESULTS

Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002).

CONCLUSIONS

Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients' actively dying status.

Integrating Palliative and Oncology Care for Patients with Advanced Cancer: A Quality Improvement Intervention

BACKGROUND

Practice guidelines recommend palliative care for patients with advanced cancer, but gaps in access and quality of care persist.

OBJECTIVE

To increase goals-of-care (GOC) communication for hospitalized patients with Stage IV cancer.

METHODS

An interdisciplinary team designed a quality improvement intervention to enhance oncology palliative care, including training in communication skills and triggers for palliative care consults.

SETTING/SUBJECTS

All adult inpatients with Stage IV cancer and unplanned admission at an 804-bed hospital affiliated with a National Cancer Institute (NCI) Comprehensive Cancer Center.

MEASUREMENTS

The primary quality measure was the percentage of patients with Stage IV cancer who had a GOC discussion during hospitalization; secondary measures included screening for pain, dyspnea, spiritual needs, and outcomes of intensive care, hospice, and 30-day readmission.

RESULTS

In the 11-month study period, n = 330, Stage IV cancer patients were hospitalized. Comparing the first three months with the final three months, rates of GOC discussion increased from 29% to 48% (p = 0.013), and specialty palliative care consultation increased from 18% to 33%, (p = 0.026). Rates of symptom screening, intensive care unit transfer, hospice, and 30-day re-admission did not change overall. However, patients with specialty palliative care more frequently had pain screening (91% vs. 81%, p = 0.020), spiritual assessment (48% vs. 10%, p < 0.001), and hospice referral (39% vs. 9%, p < 0.001), and they were less likely to be re-admitted within 30 days (12% vs. 21%, p = 0.059).

DISCUSSION

Interdisciplinary quality improvement was effective to increase GOC discussions and palliative care consults for patients with Stage IV cancer.

Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review

PURPOSE

Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, inability to access prior documentation, or poor documentation quality. Interventions utilizing tools within the electronic health record (EHR) may address these barriers at the point of care. We aimed to identify EHR interventions previously utilized to improve advance care plans.

METHODS

We systematically searched 7 databases for observational and experimental studies of EHR interventions associated with advance care plans. We abstracted information on the study populations, EHR and non-EHR components of the interventions, and the efficacy for advance care plan-related outcomes.

RESULTS

We identified 16 articles that contained an EHR intervention to improve advance care plans. Study populations, study designs, and EHR components of the interventions were heterogeneous. Documentation templates were the most common EHR tool reported (n = 8), followed by automated prompts (n = 7) and electronic order sets (n = 5). The most common reported outcomes were documentation of an advance care planning conversation in the EHR (n = 7) and the placement of code status orders (n = 7). All studies reporting efficacy (n = 9) demonstrated an improvement in 1 or more advance care planning outcomes.

CONCLUSIONS

The use of EHR interventions may improve advance care plan completion and availability at the point of care. Further work should seek to develop and evaluate standardized EHR tools for advance care planning.

Does educating patients about the Early Palliative Care Study increase preferences for outpatient palliative cancer care? Findings from Project EMPOWER

OBJECTIVES

Randomized controlled trials, especially the Early Palliative Care Study (Temel et al., 2010), have shown that early outpatient palliative cancer care can improve quality of life for patients with advanced cancer or serious symptoms. However, fear and misconceptions drive avoidance of palliative care. Drawing from an empowerment perspective, we examined whether educating patients about evidence from the Early Palliative Care Study would increase preferences for palliative care.

METHOD

A sample of 598 patients with prostate, breast, lung, colon/rectal, skin, and other cancer diagnoses completed an Internet-mediated experiment using a between-group prepost design. Intervention participants received a summary of the Early Palliative Care Study; controls received no intervention. Participants completed baseline and posttest assessments of preferences of palliative care. Analyses controlled for age, gender, education, cancer type, presence of metastases, time since diagnosis, and baseline preferences.

RESULTS

As hypothesized, the intervention had a favorable impact on participants' preferences for outpatient palliative cancer care relative to controls (d = 1.01, p < .001), while controlling for covariates. Intervention participants came to view palliative care as more efficacious (d = 0.79, p < .001) and less scary (d = 0.60, p < .001) and exhibited stronger behavioral intentions to utilize outpatient palliative care if referred (d = 0.60, p < .001). Findings were comparable in patients with metastatic disease, those with less education, and those experiencing financial strain.

CONCLUSIONS

Educating patients about the Early Palliative Care Study increases preferences for early outpatient palliative care. This research has implications for future studies aimed at improving quality of life in cancer by increasing palliative care utilization. (PsycINFO Database Record

A New Generation of Comfort Care Order Sets: Aligning Protocols with Current Principles

BACKGROUND

There are few published comfort care order sets for end-of-life symptom management, contributing to variability in treatment of common symptoms. At our academic medical centers, we have observed that rapid titration of opioid infusions using our original comfort care order set's titration algorithm causes increased discomfort from opioid toxicity.

OBJECTIVE

The aim of this study was to describe the process and outcomes of a multiyear revision of a standardized comfort care order set for clinicians to treat end-of-life symptoms in hospitalized patients.

DESIGN

Our revision process included interdisciplinary group meetings, literature review and expert consultation, beta testing protocols with end users, and soliciting feedback from key committees at our institutions. We focused on opioid dosing and embedding treatment algorithms and guidelines within the order set for clinicians.

SETTING

The study was conducted at two large academic medical centers.

RESULTS

We developed and implemented a comfort care order set with opioid dosing that reflects current pharmacologic principles and expert recommendations. Educational tools and reference materials are embedded within the order set in the electronic medical record. There are prompts for improved collaboration between ordering clinicians, nurses, and palliative care.

CONCLUSIONS

We successfully developed a new comfort care order set at our institutions that can serve as a resource for others. Further evaluation of this order set is needed.

Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness

BACKGROUND

As in other areas of health delivery, there is a need to ensure that end-of-life care is guided by patient centred research. A systematic review was undertaken to examine the quantity and quality of data-based research aimed at improving the (a) processes and (b) outcomes associated with delivering end-of-life care in hospital settings.

METHODS

Medline, EMBASE and Cochrane databases were searched between 1995 and 2015 for data-based papers. Eligible papers were classified as descriptive, measurement or intervention studies. Intervention studies were categorised according to whether the primary aim was to improve: (a) end of life processes (i.e. end-of-life documentation and discussions, referrals); or (b) end-of-life outcomes (i.e. perceived quality of life, health status, health care use, costs). Intervention studies were assessed against the Effective Practice and Organisation of Care methodological criteria for research design, and their effectiveness examined.

RESULTS

A total of 416 papers met eligibility criteria. The number increased by 13% each year (p < 0.001). Most studies were descriptive (n = 351, 85%), with fewer measurement (n = 17) and intervention studies (n = 48; 10%). Only 18 intervention studies (4%) met EPOC design criteria. Most reported benefits for end-of-life processes including end-of-life discussions and documentation (9/11). Impact on end-of-life outcomes was mixed, with some benefit for psychosocial distress, satisfaction and concordance in care (3/7).

CONCLUSION

More methodologically robust studies are needed to evaluate the impact of interventions on end-of-life processes, including whether changes in processes translate to improved end-of-life outcomes. Interventions which target both the patient and substitute decision maker in an effort to achieve these changes would be beneficial.

Minimum number of clusters and comparison of analysis methods for cross sectional stepped wedge cluster randomised trials with binary outcomes: A simulation study

BACKGROUND

Stepped wedge cluster randomised trials frequently involve a relatively small number of clusters. The most common frameworks used to analyse data from these types of trials are generalised estimating equations and generalised linear mixed models. A topic of much research into these methods has been their application to cluster randomised trial data and, in particular, the number of clusters required to make reasonable inferences about the intervention effect. However, for stepped wedge trials, which have been claimed by many researchers to have a statistical power advantage over the parallel cluster randomised trial, the minimum number of clusters required has not been investigated.

METHODS

We conducted a simulation study where we considered the most commonly used methods suggested in the literature to analyse cross-sectional stepped wedge cluster randomised trial data. We compared the per cent bias, the type I error rate and power of these methods in a stepped wedge trial setting with a binary outcome, where there are few clusters available and when the appropriate adjustment for a time trend is made, which by design may be confounding the intervention effect.

RESULTS

We found that the generalised linear mixed modelling approach is the most consistent when few clusters are available. We also found that none of the common analysis methods for stepped wedge trials were both unbiased and maintained a 5% type I error rate when there were only three clusters.

CONCLUSIONS

Of the commonly used analysis approaches, we recommend the generalised linear mixed model for small stepped wedge trials with binary outcomes. We also suggest that in a stepped wedge design with three steps, at least two clusters be randomised at each step, to ensure that the intervention effect estimator maintains the nominal 5% significance level and is also reasonably unbiased.

What are the barriers to initiating end-of-life conversations with patients in the last year of life?

INTRODUCTION

Improving end of life care is a national imperative. Unsatisfactory care persists particularly in acute hospitals, with shortcomings, variability in communication and advance care planning identified as fundamental issues. This review explored the literature to identify what is known about the barriers to initiating end-of-life conversations with patients from the perspective of doctors and nurses in the acute hospital setting.

METHOD

Six electronic databases were searched for potentially relevant records published between 2008 and 2015. Studies were included if the authors reported on barriers to discussing end of life with families or patients as described by doctors or nurses in hospital settings, excluding critical care.

RESULTS

Of 1267 potentially relevant records, 12 were included in the review. Although there is limited high-quality evidence available, several barriers were identified. Recurrent themes within the literature related to a lack of education and training, difficulty in prognostication, cultural differences and perceived reluctance of the patient or family.

CONCLUSIONS

This study illustrated that, in addressing barriers to communication, consideration needs to be extended to include how to embed good communication practice between patients and health professionals into the culture of this setting. Board level commitment is required to raise awareness of, and familiarity with, policies and protocols concerning communication and end-of-life care. Communication training should include practical skills and tools, opportunities to explore the personal beliefs of practitioners and managing their emotions, opportunities to analyse the local organisational (physical and social environment) and team barriers.

Patient Safety and End-of-Life Care

The current state of the science in the fields of patient safety and palliative and end-of-life care have many issues in common. This article synthesizes recent systematic reviews and additional research on improving patient safety and end-of-life care and compares each field’s perspective on common issues, both in traditional patient safety frameworks and in other areas, and how current approaches in each field can inform the other. The article then applies these overlapping concepts to a key example area: improving documentation of patient preferences for life-sustaining treatment. The synthesis demonstrates how end-of-life issues should be incorporated into patient safety initiatives. In addition, evaluating overlap and comparable issues between patient safety and end-of-life care and comparing different perspectives and improvement strategies can benefit both fields.

Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

BACKGROUND

Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials.

METHODS

Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design.

RESULTS

This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used.

CONCLUSIONS

Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.

Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium

CONTEXT

Palliative care for the older person is often limited, resulting in poor quality of dying. Pharmacological management can be one of the components to achieve better symptom control.

OBJECTIVES

To describe the anticipatory prescription of medication for symptomatic treatment and the deprescription of potentially inappropriate medication during the last days of life.

METHODS

This was a cross-sectional descriptive study between October 1, 2012 and September 30, 2013 in 23 acute geriatric wards in Flanders, Belgium. Structured after-death questionnaires were filled out by the treating geriatrician for patients hospitalized for more than 48 hours before dying.

RESULTS

Anticipatory prescription of medication was present in 65.4% of cases, 45.5% of the cases was prescribed morphine, 15.5% benzodiazepines, and 13.8% scopolamine hydrobromide. A deprescription of potentially inappropriate medication was noted in 67.9% of cases. The likelihood of anticipatory prescription was significantly higher in cases where death was expected (odds ratio [OR] 19; 95% CI 9-40; P < 0.0001) and significantly lower where dementia was present (OR 0.35; 95% CI 0.16-0.74; P < 0.006). The likelihood of deprescription was higher in cases where death was expected (OR 20; 95% CI 10-43; P < 0.0001) and in cases of patients dying from an oncological disease compared with those dying from frailty or dementia (OR 7.0; 95% CI 1.1-45.6, P = 0.042).

CONCLUSION

Anticipatory prescription of medication and deprescription of medication at the end of life in acute geriatric wards could be further optimized. A well-developed intervention to guide health care staff in patient-centered pharmacological management in the last days of life seems to be needed.

Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients

BACKGROUND

Specialty societies recommend patients with advanced cancer receive early exposure to palliative care and exposure to hospice care.

OBJECTIVE

We sought to understand real-world practice of care, specifically, the timing of palliative care, and how timing and duration of hospice care varied across Medicare, VA, and VA-Purchased care.

DESIGN

We conducted a retrospective analysis of administrative data for veterans aged 65 years or older who died with cancer in 2012. Multilevel logistic regression was used to evaluate the likelihood of receiving palliative care, receiving hospice care, and receiving hospice care for at least three days.

SETTING

Medicare, VA, and VA-Purchased care environments.

MEASUREMENTS

The receipt and timing of palliative care within VA and the receipt and timing of hospice care across three healthcare environments.

RESULTS

Most veterans received hospice care (71%), whereas fewer received palliative care (52%). Among all cancer decedents, 59% received hospice care for their last three days of life. Patients who received hospice care did so a median of 20 days before death (interquartile range [IQR]: 7-46). Patients who received palliative care did so a median of 38 days before death (IQR: 13-94). Adjusted analyses revealed significant differences in receipt of palliative care across cancer type, and significant differences in receipt of hospice care across cancer type. After adjusting for age and cancer type, patients who received VA hospice care were significantly less likely to receive it for at least three days compared with patients who received VA-Purchased or Medicare hospice care.

CONCLUSIONS

There remains a gap between recommended timing of supportive services and real-world practice of care. Results suggest that difficulties in prognosticating death are not fully responsible for underexposure to hospice.

Update in Hospice and Palliative Care

BACKGROUND/OBJECTIVE

The goal of this update in hospice and palliative care is to summarize and critique research published between January 1 and December 31, 2014 that has a high potential for impact on clinical practice.

DESIGN

To identify articles we hand searched 22 leading journals, the Cochrane Database of Systematic Reviews, and Fast Article Critical Summaries for Clinicians in Palliative Care. We also performed a PubMed keyword search using the terms "hospice" and "palliative care."

MEASUREMENTS

We ranked candidate articles based on study quality, appeal to a breadth of palliative care clinicians, and potential for impact on clinical practice.

RESULTS

In this manuscript we have summarized the findings of eight articles with the highest ratings and make recommendations for clinical practice based on the strength of the resulting evidence.

Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial

BACKGROUND

Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care.

OBJECTIVE

The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients.

METHODS

Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005-2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention.

RESULTS

The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death.

CONCLUSIONS

Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial

BACKGROUND

The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting.

OBJECTIVE

The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults.

METHODS

Secondary analysis was performed on data from the "Best Practices for End-of-Life Care for Our Nation's Veterans" (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation.

RESULTS

Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics.

CONCLUSIONS

This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities.

Awareness and completion of advance directives in older Korean-American adults

There has been growing concern about racial and ethnic disparities in completion rates of advance directives (ADs) in community-dwelling older populations. Although differences in AD completion rates between non-Hispanic whites and African Americans have been reported, not much is known about the awareness and completion of ADs in other groups of ethnic minorities. Using a sample of community-dwelling Korean-American older adults (n=675) as a target, factors associated with their awareness and completion of ADs were explored. Guided by Andersen's behavioral health model, predisposing (age, sex, marital status, education), need (chronic conditions, functional disability), and enabling (health insurance, acculturation) variables were included in the separate logistic regression models of AD awareness and AD completion. In both models, acculturation was found to be a significant predictor; those who were more acculturated were more likely to be aware of ADs and to have completed ADs. This study contributes to the knowledge about the role of acculturation in explaining AD awareness and completion in Korean-American older adults and provides recommendations for possible AD educational interventions for this older adult minority population.

Changes in medication profile among patients with advanced cancer admitted to an acute palliative care unit

PURPOSE

The decision-making process for medication use in the last weeks of life is complex because of patient frailty and poor prognosis. Limited literature is available on medication use in the palliative care setting, particularly in acute palliative care units (APCUs). We examined the changes in medication profile among hospitalized patients with advanced cancer before their palliative care inpatient consultation team referral, after palliative care consultation, at the time of APCU admission, and at APCU discharge or death.

METHODS

We included consecutive patients with advanced cancer who were first seen by our inpatient palliative care consultation team and subsequently admitted to the APCU. We retrieved data on all scheduled medications at the prespecified time points.

RESULTS

Among the 100 patients, the median duration of hospitalization was 10.5 days (interquartile range 8-15 days), and the median APCU stay was 5 days (interquartile range 3-7 days). The average number of medications before palliative care inpatient consultation team referral, after palliative care consultation, at APCU admission and at APCU discharge/death was 9.2 (standard deviation [SD] 4.5), 9.9 (SD 4.2), 10.3 (SD 3.8), and 10.1 (SD 3.8), respectively (P = 0.03). An increasing proportion of patients received medications for symptom control over their course of hospitalization, including systemic corticosteroids, laxatives, neuroleptics, and antiulcer agents (P < 0.05). In contrast, the frequency of several classes of medications such as antihypertensives, antilipemics, and anticonvulsants decreased over time (P < 0.05).

CONCLUSIONS

Palliative care involvement was associated with an increase in symptom control medications and decrease in medications for comorbid conditions over time.

Benzodiazepine and sedative-hypnotic use among older seriously Ill veterans: choosing wisely?

PURPOSE

The 2014 American Geriatrics Society's Choosing Wisely list cautions against the use of any benzodiazepines or other sedative-hypnotics (BSHs) as initial treatments for agitation, insomnia, or delirium in older adults. Because these symptoms are prevalent among hospitalized patients, seriously ill older adults are at risk of receiving these potentially inappropriate medications. The objectives of this study were to understand the extent to which potentially inappropriate BSHs are being used in hospitalized, seriously ill, older veterans and to understand what clinical and sociodemographic characteristics are associated with potentially inappropriate BSH use.

METHODS

We reviewed medical records of 222 veterans aged ≥65 years who were hospitalized in an acute care facility in the New York-New Jersey metropolitan region in fiscal years 2009 and 2010. Veterans had diagnoses of advanced cancer, chronic obstructive pulmonary disease, congestive heart failure, and/or HIV/AIDS and received inpatient palliative care. Associations among potentially inappropriate BSH use (BSHs for indications other than alcohol withdrawal and current generalized anxiety disorder or one-time use before a medical procedure) and clinical and sociodemographic characteristics were examined with multivariable logistic regression.

FINDINGS

One-fifth of the sample was prescribed a potentially inappropriate BSH during the index hospitalization during the study period (n = 47). The most commonly prescribed potentially inappropriate medications were zolpidem (n = 26 [11.7%]) and lorazepam (n = 19 [8.9%]). Hispanic ethnicity was significantly associated with prescription of potentially inappropriate BSHs among the entire sample (adjusted odds ratio [AOR] = 3.79; 95% CI, 1.32-10.88) and among patients who survived until discharge (n = 164; AOR = 5.28; 95% CI, 1.64-17.07). Among patients who survived until discharge, black patients were less likely to be prescribed potentially inappropriate BSHs than white patients (AOR = 0.35; 95% CI, 0.13-0.997), and patients who had past-year BSH prescriptions were more likely to be prescribed a potentially inappropriate BSH than patients without past-year BSH use.

IMPLICATIONS

The potentially inappropriate BSHs documented in our sample included short- and intermediate-acting benzodiazepines, medications that were not identified as potentially inappropriate for older adults until after these data were collected. Few long-acting benzodiazepines were recorded, suggesting that the older veterans in our sample were receiving medications according to the guidelines in place at the time of hospitalization. Clinicians may be able to reduce prescriptions of newly identified inappropriate BSHs by being aware of medications patients received before hospitalization and by being cognizant of racial/ethnic disparities in symptom management. Future studies should explore reasons for disparities in BSH prescriptions.