A study by researchers at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham says using home-based hospice practices for terminally ill, hospitalized patients could reduce suffering and improve end-of-life care.
The study, published online Jan. 21 in the Journal of General Internal Medicine, is the first to show that palliative care techniques usually used in a home setting can have an impact on end-of-life care for those who die in a hospital.
"More than 75 percent of Americans say they would prefer to die at home, yet only about 25 percent do — the vast majority dying in hospitals or nursing homes," said Amos Bailey, M.D., director of the Safe Harbor Palliative Care Program at the Birmingham VAMC and professor in the Division of Gerontology, Geriatrics and Palliative Care in the UAB School of Medicine. "This study was designed to see whether home-based hospice practices could be successfully integrated into care in hospitals to improve the end-of-life experience for those who remain hospitalized at time of death."
The study, Best Practices for End-of-Life Care for Our Nation's Veterans, or BEACON, was conducted at six VA Medical Centers over six years between 2005 and 2011 and included more than 6,000 patients.
The multicomponent intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients and families, and implement best practices of traditionally home-based hospice care in the inpatient setting. The intervention was supported by an electronic order set — called a comfort care order set — and other educational tools to prompt and guide implementation.
"Our intent was to take best practices commonly used in home hospice and translate those to the hospital setting," said Kathryn Burgio, Ph.D., associate director for research at the Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center and professor in the UAB Division of Gerontology, Geriatrics and Palliative Care.
BEACON examined several variables such as orders and use of medications for pain or confusion. It encouraged a more homelike environment that allowed the family to stay with their loved one or allowed people to eat some of the foods and drink they particularly like. It suggested less emphasis on the use of bedside monitoring and invasive procedures.
The study developed a screening tool for medical professionals to better assess when death was imminent — within a few days or a week. The comfort care order set could then be added to the patient's treatment plan. The orders prompted medical staff to adopt typical hospice practices such as providing easier access to pain medications and allowing patients to sit up in a chair, particularly beneficial for those with heart or lung disease. If supplemental oxygen was needed, BEACON recommended its delivery through the least invasive means possible.
"We wanted an environment where the care given in the hospital was more like that available at home with hospice," said Bailey.
The research team then created a list of measureable process outcomes that could be used to assess the effectiveness of the BEACON intervention. They included reducing intensive care unit usage, use of appropriate medications for pain, anxiety and respiratory issues, need for restraints, and use of pastoral care or palliative care consultation.
"Every one of the 16 outcomes we measured improved after implementation of the BEACON intervention," said Burgio. "For example, orders for pain medication increased from 62 percent to 73 percent. The percentage of patients who had IV lines or feeding tubes was lowered. The percentage who received appropriate medication for confusion or congested breathing increased. These are all variables that help ensure a less painful, less stressful and more comfortable end-of-life experience."
Bailey says the comfort care order set is now routinely used at the Birmingham VA Medical Center, as well as the UAB Palliative and Supportive Care inpatient unit.
"The BEACON protocol could be used in any hospital, and an increasing number of facilities have begun to adopt similar plans based on our findings," said Bailey. "We have submitted a grant to expand the program into another 48 VA hospitals nationwide."
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