Published in the January 2006 issue of Today’s Hospitalist
As a growing number of U.S. hospitals develop inpatient palliative care programs, many are discovering that developing an end-of-life care consult service is only the beginning of a long process. The next “and critical “step is making sure that physicians use those services to help care for patients near the end of life.
Physicians and nurses often hesitate to request a palliative care consult for a variety of reasons. They may not feel comfortable predicting when patients are going to die, or end-of-life measures may simply take a back seat to more curative measures.
While previous research has shown that physician education alone doesn’t go far enough in changing physicians’ attitudes toward palliative care, a new study shows that there are some very tangible things these programs can do to work more closely with physicians.
The study, which was published in the Aug. 8/22, 2005, Archives of Internal Medicine, found that two tools “a pocket card outlining end-of-life symptoms and a comfort care order set that gives clinicians guidance on how to alleviate those symptoms ” went a long way toward not only toward convincing physicians to request a palliative care consult, but also improved the care of hospitalized patients in their last hours of life.
Taking a page from hospice
The goal of the study, which was led by a group of researchers at the Birmingham VA Medical Center in Alabama, was simple:
Implement the best practices of hospice care in the inpatient setting because that’s where so much end-of-life care takes place.
The study’s lead author, F. Amos Bailey, MD, director of palliative care at the Birmingham VA, says he wanted to address a complaint that he hears all the time from his colleagues in palliative care: “I wish physicians and nurses would call me earlier.”
While Dr. Bailey says it’s true that physicians often wait too long to start thinking of palliative care, he says it’s never too late to ask for an end-of-life care consult.
“Even if a patient is within a few hours of death,” he says, “there is frequently a lot we can do to help that patient’s symptoms. We want patients to have a good palliative medicine experience for their whole hospital stay, but we know this is a particular problem area.”
So Dr. Bailey, who is also assistant professor at the University of Alabama, Birmingham’s division of geriatrics, took a page from the world of hospice. When hospice nurses recognize that a patient is entering the final hours of life, he explains, they switch gears and adopt a comfort care approach.
Identifying patients near death
The researchers realized that they would need to help physicians identify patients near the end of life. But instead of simply teaching clinicians how to identify the signs that death is imminent, the palliative care team created an easy-to-use tool that had much more staying power.
The “Consider Palliative Care” pocket card lists 13 symptoms that clinicians can use to identify patients who have a high likelihood of dying. Those “symptoms” include a DNR order, a length of stay of greater than seven days, bed confinement, minimal fluid intake and an inability to take oral medications.
While the pocket card was a huge success “it is currently being used by VA hospitals throughout the Southeast “it was only the beginning of the team’s efforts to help identify candidates for palliative care. Dr. Bailey explains that the palliative care team took an innovative approach to get physicians thinking about whether the patient was likely going to die. The approach is unique, he says, because it addresses the reluctance of many physicians to prognosticate their patients’ survival.
Instead of asking clinicians to predict exactly when a patient will die, the team asked for less precise estimates. “We would ask physicians if they thought the patient was hours to days away from death, days to weeks or weeks to months,” Dr. Bailey explains. “People can usually put patients into one of those three categories.”
“If you ask who is likely to die in the next day, physicians and others are very reluctant to say definitively, because no one can really predict,” he adds. “But asking them to choose between these three categories helped people begin to select.”
Comfort care orders
When physicians estimated that a patient was likely to die in hours or days, the palliative care team would strike up a conversation about palliative care and introduce another tool: comfort care order sets.
These order sets give clinicians specific advice on how to manage common end-of-life symptoms like pain, dyspnea, nausea, depression and seizures. The order sets also encouraged staff to make dying patients more comfortable by using fewer restraints, feeding tubes and IV lines, by working with social workers and pastoral support, and by discontinuing unnecessary medications when possible.
Dr. Bailey says the order sets gave clinicians a reason to look for signs that their patients were entering the dying process.
“If your patient is short of breath but you don’t have anything you can do for that condition,” he explains, “it’s discouraging to write that down. Giving clinicians the order set, which had management strategies for each of the symptoms, empowered them to look for symptoms because they knew what to do about it.”
And to make physicians comfortable with the notion of giving their patients palliative care, the consult team didn’t demand that other treatment be discontinued just because end-of-life measures were being discussed. If a patient who appeared to be dying was still receiving other therapies like antibiotics, Dr. Bailey says, the palliative care team would take a low-key approach.
“We would propose continuing the antibiotics as a time trial, something that we could revisit in 48 hours,” he explains. “In the meantime, we would use the comfort care order set to try to better control the patient’s other symptoms.”
Often times, Dr. Bailey says, it would become clear that the nonpalliative therapies were extraneous, and they would be discontinued.
One benefit of starting palliative care even before other therapies are discontinued, he notes, is that it often becomes much easier to withdraw therapy like drugs or even a feeding tube. “The patients already have medications ordered that make it a more tolerable procedure,” Dr. Bailey says.
A successful intervention
Overall, the palliative care team’s efforts to change physicians’ views of palliative care paid off. The study notes that after the intervention, patients at the end of life were more likely to receive opioids, something that Dr. Bailey says is a key goal of palliative care programs.
Researchers also found an increase in the number of documented end-of-life symptoms for patients, as well as an increase in the number of care plans and DNR orders.
And while the intervention was led by a palliative care team, Dr. Bailey says that at least some components of the project could be adopted by hospitalists, even in facilities that don’t have a palliative care program.
He explains that using the pocket cards to identify patients who have a high risk of dying would be a good place to start. Physicians can download and freely reproduce the cards, which are available online. (Click on the “palliative response” button on the left side of the page and look for the “download palliative response pocket cards” button on the bottom left of the page.)
“Having a palliative care consult service helps improve the ability to use the order sets,” Dr. Bailey says, “but it isn’t absolutely required. Hospitalists who are frequently admitting patients who are actively dying could use something like this to guide their order-writing for patients who are coming into the hospital for terminal care.”
Edward Doyle is Editor of Today’s Hospitalist.