Sometimes relatively simple solutions to problems reside right under our often non-seeing noses. But first it's necessary to recognize that there is a problem, and then it's necessary to want to do something about it.
Such has often been the case with the state of quality of care for hospitalized patients facing imminent death, with the focus more often on providing intensive medical treatments rather than making patients more comfortable through palliative symptom management.
Now, the beginning of a system to improve quality of care for hospitalized patients at the end of life has been proposed in an article in Archives of Internal Medicine (2010;170:1057-1063). The proposal addresses the creation of a systematic measurement for quality-of-life and palliative care for dying patients with distressing symptoms who are not responsive to intensive medical treatments.
Writing on Twitter, Diane E. Meier, MD, Director of the Center to Advance Palliative Care and of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine, said the article provides important new information on quality metrics for palliative care in hospitals.
The research team for the study, with first author Anne M. Walling, MD, of the Division of General Internal Medicine and Health Services Research and the Health System Ethics at David Geffen School of Medicine, concluded that a medical chart-based assessment identifying “discrete deficiencies in care planning and symptom palliation can be targeted to improve care for patients dying in the hospital.”
The preliminary findings received a Geriatric Abstract Award from the Society of General Internal Medicine when they were presented last year at that organization's Annual National Meeting.
Do These 3 Things
Dr. Walling explained in an interview that according to the findings, clinicians can better benefit their hospitalized patients who are dying by doing three things:
* Include quality indicators focusing on communications and symptom management in quality review.
* Engage clinicians and health care staff in discussions regarding areas that may require improvement at their hospitals.
* Use this information for quality improvement initiatives.
Dr. Walling and her colleagues abstracted 16 (out of 392) Assessing Care of Vulnerable Elders (ACOVE) quality indicators dealing with end-of-life care and pain management from medical records to measure the quality of the dying experience for 496 adults who were a mean 62 years old and who had been hospitalized for at least three days between April 2005 and April 2006 at UCLA Medical Center.
The quality indicators primarily involved the goals of care, pain assessment and management, and dyspnea assessment and management. More than half the patients were admitted with end-stage disease, one-third required estuation from mechanical ventilators before death, and 15% died during cardiopulmonary resuscitation.
“Our goal was to find areas to develop interventions to improve care and was meant to be a process of improvement,” Dr. Walling said. “We wanted to use measures that focus on quality of end-of-life care especially related to symptom control and communication. Basically, high-quality care should include not just best curative therapies but also the best palliative supportive therapies.”
Most in Need of Improvement: Communication
The study found that communications between physicians and patients or their families was the area most in need of quality improvement.
Other areas found to need improvement were assessment of dyspnea, deactivating implantable cardioverter-defibrillators, and bowel regimens for patients taking opioids.
The study also tested the reliability of the quality indicators by having different trained nurses extract data from medical records and getting the same results.
Dr. Walling said the study did have limitations in that it was done at a single institution, and that only patients who died in the hospital were included.
“Ideally we would have liked to sample all patients with a high risk of dying and capture those who died elsewhere, at home or a hospice,” she said.
The current findings at her institution might also be different today, she noted, since palliative care has increased its visibility over the intervening years. Future expansion of the indicators during the end-of-life process might include supporting caregivers as well as looking at spiritual issues, she added.
Diane Meier: Final Days/Weeks ‘Burned into the Memories of Survivors’
In an interview while she was in Washington, DC, working with the US Senate Committee on Health, Education, Labor, & Pensions as a 2009-2010 Health and Aging Policy Fellow, Dr. Meier, who is also Professor of Geriatrics and Internal Medicine at Mount Sinai School of Medicine and a MacArthur Fellow for her contributions to palliative care, said the study is a reminder that in the United States, about 53% of people still die in hospitals.
“With the exception of the SUPPORT [Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments] study published in 1995, we know very little about the quality of care that is delivered at this very critical developmental stage of life—that is, the last days and weeks of life. And it's important to remember that what happens during those days and weeks is basically burned into the memories of the survivors.”
Dr. Meier said that the trauma of the care that isn't done often stays with people for the rest of their lives, and has a major impact on survivors, often causing distrust of doctors or the health care system, and is also associated with post-traumatic stress disorder and other adverse bereavement health outcomes in survivors.
“So what's important about this study is that it provides us with a fairly brief, valid instrument to assess the quality of care delivered in hospitals to people who ultimately died during their stay in the hospital.
“You can do it with chart review and the advantage of that is that it doesn't require very costly telephone interviews and tracking people down to get the information about what happened. All these metrics are extractable from the medical records, which is a much easier way for hospitals to assess quality. The study found that there are many areas that are being done reasonably well, but just as many areas that dramatically need improvement, which is no surprise.
“But the good news is that what we have here now is an instrument that can hold a hospital's feet to the fire.”
10% Random Sampling
Dr. Meier said that since the study offers a practical tool that involves using only medical charts, that hospitals should consider having graduate or summer students do a 10% random sampling of all deaths in their institutions during a given year by using this instrument and it will then be possible for the hospitals to see whether they are doing well or not, and will have a path to see what had happened.
“We haven't had quality measures like this before, so this is a huge step forward for giving patients and families and future patients and families hope that when they are in a hospital the care they receive if they are coming to the end of their days will be of the highest possible quality. We have not been able to measure that before.”