| Principal Investigator: | Rosemary Chacko, MD, FACP, FAIHQ |
| Co-Principal Investigators/Collaborators: | Betsy Swinny, Jonathan Rivera |
| Organization: | Baptist Health System |
Abstract
Problem
Scenarios with patients dying “in full code” often represent a failure to communicate.
Evidence
In a 2007 study of patients who died in the ICU, as the hospitalization progressed, 86% of the physicians felt that death was imminent. Only 11% of the physicians spoke to the patients about the possibility of dying. Physicians that recognized and addressed the imminently dying patient were more likely to have caregiver satisfaction. {Sullivan AM, 2007 #10} Helft reviewed 284 death charts. Even with a diagnosis of cancer with terminal decline only 77% had documented DNR orders at End of Life. {PR Helft, 2007 #12}. At SLBH, a three-month death chart review from Jan 08 to April 08 showed similar findings with 18% of patients dying in a full code. Discussions were documented as occurring with a family member, yet often details, other than “time spent” were omitted.
Strategy
In August 2008, we instituted a Palliative Care Infrastructure Project in the ICU at SLBH. The goals were to improve symptom control, communication of patient wishes, recognition and comfort care of dying patients, and offer out-of-hospital options for care of terminal patients. A Plan-Do-Study Act design with comparison cohort prior to intervention was chosen.
Practice Change
The interventions included physician prompts, a chart prompt every 72 hours to document patient/family wishes in the medical record, a sample family conferencing progress note, and resources of physician suggestions for symptom management.
Evaluation
All hospital deaths of inpatients > 18 were reviewed for the next three months. Code status at death, documentation of patient/family concerns, opioid presence or absence on MAR at EOL, Length of Stay in ICU and in hospital, and DNR timing if present. Hospice Referral Rate per 1000 discharge, and Hospital Death Rate per 1000 discharge were calculated.
Results
Patients dying in full code decreased by 50%. (Patients dying without an opioid for symptoms decreased by 25%) Lengths of Stays decreased. Inpatient Death Rate decreased by 20%. Hospice Referral Rate increased by 18% for the three months compared to the year prior.
Recommendations
Spread practice throughout hospital.
Lessons Learned
Chart documentation of patient/family wishes IN THEIR OWN WORDS improved communication and patient centered care.
Bibliography
- F. Amos Bailey, MD. The Palliative Response. Menasha Ridge Press: 2005.
- Elizabeth A Kvale MD, W. B. R. e. a. (2004). “The Balm of Gilead Project: A Demonstration Project on End-of-Life Care for Safety-Net Populations.” Journal Of Palliative Medicine 7(3): 486–494.
- Formiga F, O. C., López-Soto A, Navarro M, Culla A, Pujol R (2007). “Dying in hospital of terminal heart failure or severe dementia: the circumstances associated with death and the opinions of caregivers.” Palliative Medicine 21(1): 35–40.
- G DuVal, C. B. e. a. (2004). “A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation.” Journal Of General Internal Medicine 19(3): 251–8.
- G Gade, V. O. e. a. (2008). “Impact of an inpatient palliative care team; a randomized control trial.” Journal Of Palliative Medicine 11(2): 180–190.
- JE Nelson, A. D., Weissfeld LA et al (2006). “End-of life care for the critically ill; A national intensive care unit survey.” Critical Care Medicine 34(10): 2547–53.
- Lueke T, M. E., Roth H, Friess U, Paul T, et al (2006). “Predictor of mortality in ARDS patients referred to a tertiary care centre: a pilot study.” Eur J Anaesthesiol 23(5): 403–10.
- Marla R. London, M. L., J. MS,RN, CNS (2007). “Families Speak About Inpatient End-of-Life Care.” J Nurs Care Qual 22(2): 152–158.
- American Academy of Hospice and Palliative Medicine — (2007). “Statement on Palliative Care Research Ethics.” http://www.aahpm.org/positions/researchethics.html.
- Michele Solloway, P., LaFrance S, MS, MPH et al. (2005). “Chart Review of Seven Hundred Eighty-Two Deaths in Hospitals, Nursing Homes, and Hospice/HomeCare.” Journal Of Palliative Medicine 8(4): 789–796.
- PR Helft, R. Q., BP Brown et al (2007). “DNR patterns in cancer patients 16 years after the Patient Self Determination Act (PSDA) ABSTRACT of Presentation at the ASCO Annual Meeting Proceedings.” Journal of Clinical Oncology 25(18S): 6582.
- Sullivan AM, L. M., Matsuyama RK, Rosenblatt L, Arnold RM, Block SD (2007). “Diagnosing and discussing imminent death in the hospital: a secondary analysis of physician interviews.” Journal Of Palliative Medicine 10(4): 882–93.
- Veysman, B. (2005). “Full Code.” Health Affairs 24(5): 1311–6.