Taking a Hint from Home Hospice Care to Help Those Who Die in Hospitals
Adopting best practices from home-based hospice care in the inpatient environment can reduce suffering at the end of life, according to a study published in the Journal of General Internal Medicine. Researchers at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham said the study is the first to show that palliative care techniques usually used in home settings can have an impact on those who die in hospitals.
The Best Practices for End-of-Life Care for Our Nation’s Veterans (BEACON) trial was conducted at six Veterans Affairs Medical Centers from 2005 to 2011 and involved training more than 1,620 staff members in aspects of care for more than 6,000 dying patients. Although focused on veterans, the study can have a wider impact, researchers said, because most Americans will die in the inpatient setting of a hospital or nursing home.
“We only die once, and therefore there is only one opportunity to provide excellent care to a patient in the last days of life,” wrote lead author F. Amos Bailey, MD, director of the Safe Harbor Palliative Care Program at the Birmingham Veterans Affairs Medical Center, professor in the Division of Gerontology, Geriatrics and Palliative Care at the University of Alabama at Birmingham School of Medicine, and a 2000 Robert Wood Johnson Foundation Community Health Leader. “The keys to excellent end-of-life care are recognizing the imminently dying patient, communicating the prognosis, identifying goals of care, and anticipating and palliating symptoms. Since it is not possible to predict with certainty which symptoms will arise, it is prudent to have a flexible plan ready.”
Staff training focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set, known as a comfort care order set, and other education tools. Researchers found that this broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, including more orders for opioid medication for pain and shortness of breath; antipsychotic and benzodiazepine medications for delirium, agitation, and anxiety; and medications for rattling breathing (sometimes known as death rattle).
The removal of nasogastric tubes and the presence of advance directives also highlighted the value of a more comprehensive plan that preempts and decreases the anticipated distress of patients and families in the final hours of life.