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Author List:
Kovac SH (Durham VAMC, Center for Health Services Research in Primary Care; Duke University, School of Medicine)
Bailey FA (Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC); University of Alabama at Birmingham (UAB), School of Medicine)
Woodby LL (Birmingham/Atlanta GRECC; UAB School of Medicine)
Williams BR (UAB School of Medicine)
Redden DT (Birmingham/Atlanta GRECC; UAB School of Medicine and School of Public Health)
Durham RM (Birmingham VAMC)
Goode PS (Birmingham/Atlanta GRECC; UAB School of Medicine)
Objectives:
To evaluate hospitalized end-of-life processes of care after the implementation of a provider-level intervention at the Birmingham Veterans Affairs Medical Center (BVAMC).
Methods:
The intervention included education on end-of-life care, including identifying patients entering the dying process and the implementation of a CPRS order set on end-of-life processes of care for both nurses and physicians. The study compared changes in end-of-life processes of care pre- and post-intervention. The following end-of-life processes of care measures were evaluated: 1) opioid medication availability at time of death, 2) presence of a Do Not Resuscitate (DNR) order, 3) location of death (intensive care unit versus other unit), 4) presence of a nastogastric (NG) tube at the time of death, and 5) whether the patient was in restraints at or near the time of death. In addition, the documentation of 13 end-of-life symptoms (e.g., pain, dyspnea, continence) was also assessed pre and post.
Results:
A total of 203 veterans who died in the hospital were identified (108 in first 6 months of FY01; 95 in first 6 months of FY03). The two groups did not have significant differences in number of inpatient and outpatient admissions. Two out of the 5 processes of care measures improved from pre to post-intervention. Opioid medication availability significantly increased from 57% to 83% (p < .001) and DNR orders increased from 62% to 85% (p < .001). However, there were not significant pre-post differences in the location of death, presence of NG tubes, or the proportion of patients in restraints. However, there was a significant increase in the number of end-of-life symptoms documented from 1.7 (SD = 2.1) to 4.4 (SD = 2.7) (p < .001).
Implications:
In one facility, end-of-life care improved in terms of increased availability of opioid medications and a higher proportion of DNR orders.
Impacts:
A provider-level intervention involving education and the implementation of a CPRS order set may improve end-of-life care. However, the study design does not allow us to detect the potential effects of secular trends. A randomized controlled trial is needed in order to replicate the current findings.
