• F Amos Bailey, Beverly R Williams, Lesa L Woodby, Patricia S Goode, David T Redden, Thomas K Houston, U Shanette Granstaff, Theodore M Johnson, Leslye C Pennypacker, K Sue Haddock, John M Painter, Jessie M Spencer, Thomas Hartney, and Kathryn L Burgio.
• Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL, 35233, USA.
• J Gen Intern Med. 2014 Jun 1; 29 (6): 836843836-43.

BackgroundWidespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.ObjectiveTo evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.DesignImplementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.ParticipantsSix Veterans Affairs Medical Centers (VAMCs).InterventionStaff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.Main MeasuresSeveral processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.Key ResultsSignificant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.ConclusionsThis broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

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