F. Amos Bailey

Do Palliative Consultations Improve Patient Outcomes

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care.

A Nationwide VA Palliative Care Quality Measure: The Family Assessment of Treatment at the End of Life

OBJECTIVES To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN Nationwide telephone survey. SETTING Five VA medical centers. PARTICIPANTS Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patients death (3 items). RESULTS Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Disruptions in the organization of meal preparation and consumption among older cancer patients and their family caregivers

Objectives: The purpose of this paper is to analyze the social organization of caring as gendered work as it relates to meal preparation and consumption activities surrounding older adult cancer patients and their caregivers.

Do-Not-Resuscitate Orders in the Last Days of Life

BACKGROUND The purpose of this analysis was to describe the presence and timing of do-not-resuscitate (DNR) orders for imminently dying patients in VA Medical Centers, and to examine factors associated with these processes. METHODS Data on DNR orders in the last 7 days of life were abstracted from the medical records of 1,069 veterans who had died in one of six VA hospitals in 2005. RESULTS Of the 1069 records, 681 (63.7%) had an active DNR order at time of death. Among these, records indicated that the order was written within the last 24 hours for 219 (32.2%), 1-2 days prior to death for 54 (7.9%), 3-7 days prior to death for 256 (37.6%), and > 7 days prior to death for 152 (22.3%). Veterans with a family member present at time of death and those who received pastoral care visits were more likely to have DNR orders. African American veterans and veterans who died unexpectedly were less likely to have DNR orders. Compared with those dying on a general medicine unit, veterans dying in the emergency department or an intensive care unit (ICU) and veterans dying during a procedure or in transit were less likely to have DNR orders. Mental health diagnoses were not associated with presence of a DNR order. CONCLUSION Results suggest that the DNR process might be improved by interventions that target ICU settings, facilitate transitions to less intensive locations of care, ensure the involvement and availability of pastoral care staff, and create environments that support the presence of family members.

“A Room Full of Chairs around His Bed”: Being Present at the Death of a Loved One in Veterans Affairs Medical Centers

Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) “settling in,” characteristic of the experiences of wives and daughters in the initial phase of the patients hospitalization; and 2) “gathering around,” characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of familys needs and empower staff to develop policies and procedures for supporting family members.

Formative Evaluation of a Multi-Component, Education-Based Intervention to Improve Processes of End-of-Life Care

A multicomponent, palliative care, education-based intervention was implemented in six Veterans Affairs Medical Centers in the southeast United States. The intervention comprised onsite staff training plus supporting written materials, installation of an electronic order set, and follow-up consultations. Training included large-group didactic presentations, small-group clinical demonstrations, and one-on-one consultations. The intervention strategy was targeted broadly to hundreds of hospital providers, including physician, nursing, and ancillary staff. The purpose was to train staff in identifying actively dying patients and implementing best practices of home-based hospice care. A formative evaluation was conducted utilizing semistructured telephone interviews with key informants from each site. Qualitative data analysis revealed processes that facilitated or impeded uptake of the intervention. Results will be used to inform ongoing and future clinical initiatives and optimize future implementation of education-based interventions to improve adoption of best practices for end-of-life care within acute care settings.

Hospice Emergency Kit for Veterans: A Pilot Study

BACKGROUND Although the provision of hospice emergency kits (HEKs) by home hospice agencies is thought to be widespread, little is known about their use, safety, and impact. OBJECTIVE This study evaluated HEK medication utilization, safety, diversion, and perceived impact. DESIGN Evaluation consisted of a retrospective patient chart abstraction and an anonymous questionnaire for home hospice nurses. SETTING/SUBJECTS Chart abstraction examined the computerized records of deceased veterans discharged to home hospice in 2009 (N=76). The questionnaire was completed by 78 home hospice nurses from 16 agencies. MEASUREMENTS Chart abstraction examined HEK medication utilization, symptoms addressed, and safety/diversion concerns. The hospice nurse questionnaire assessed their perceptions of HEK utilization, safety, and impact, including efficacy for preventing emergency department (ED) visits and hospitalizations. RESULTS Of patients who received an HEK, its use was documented in 50% of cases. The most used items were morphine concentrate and antibiotics. Nurses estimated that the HEK was utilized in 66.3% of cases, with the most frequently used medications being morphine, lorazepam, promethazine, and haloperidol. Fifty-nine percent of nurses felt HEKs were helpful 100% of the time (mean=84.2%; median=100% of the time) and 93% felt that an emergency department (ED) visit or hospitalization was avoided by having the kit in the home. Eighteen percent believed that medications in the kit are used by someone other than the patient. CONCLUSIONS HEKs have value as a means to alleviate many symptoms that emerge predictably in home hospice patients and may avoid unwanted hospitalizations and ED visits.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life in the Acute Care Setting: An Analysis of Data from the BEACON Trial (TH318-C)

Objectives Gain an understanding of the prevalence of restraint use in dying patients. Understand what patient characteristics and care processes place a patient at greater risk for being restrained at time of death. Original Research Background: The use of physical restraints in dying patients should be limited to situations where patient death is unanticipated. Little is known about the prevalence or risk factors for restraint use at end of life. Research Objectives: To determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults. Design: conducted between 2005 and 2011. Setting/Participants: Data on the last seven days of life were abstracted from the medical records of 5,476 decedents from six Veterans Administration Medical Centers (VAMCs) in the southeast United States and from VA administrative databases. Methods: Based on literature and expert clinical opinion, we prospectively identified potential risk factors for restraint use at the time of death from among all variables collected during the trial. Factors included location of death, medications given, nasogastric tube, intravenous (IV) fluids infusing, family presence at time of death, and receipt of a palliative care consultation.

We Thought We Had More Time: Exploring Next-of-Kin Accounts of Hospice and Palliative Care Discussions for Veterans Who Died in VA Medical Centers (S766)

direct admission process and increased the frequency of verbal communication between medical providers. Background. Transitions in care are vulnerable times for patients. Standardizing workflows and communication between medical providers is thought to decrease the risk of adverse events. When transferring patients from our hospital to an inpatient hospice facility, our Palliative Care physicians are able to directly admit patients without having a separate hospice admission nurse visit to assess the patient and facilitate the transfer. This can expedite the transfer out of the hospital for patients, but some physicians are less familiar with implementing this process than others, leading to concerns about increased risk of adverse events. Research Objectives. Design and implement a standardized checklist to improve physician comfort with performing direct admissions of patients from our hospital to an inpatient hospice facility and physician communication during the transition of care. Method. We developed a checklist tool for patients being directly admitted to an inpatient hospice facility from our hospital. Preand post-intervention surveys assessed physician comfort with directly admitting patients to the inpatient hospice facility and quantified the number of verbal hand-offs given to the accepting hospice physician. Result. We surveyed seven hospital palliative care physicians. After implementation of the checklist, the mean reported comfort level with completing the direct admission process improved from 3.14 to 4 (Likert Scale, 1-5), the mean number of verbal hand-offs per month increased from 6.33 to 13.5, and the mean number of verbal hand-offs per person per month increased from 1.03 to 2.25. Conclusion. This study suggests that implementation of a standardized tool to facilitate transitions in care between a hospital and an inpatient hospice facility increases physician comfort level with the process and increases the frequency of verbal hand-offs to accepting physicians. Implications for Research, Policy, or Practice. This standardized checklist tool can be adapted for use at other institutions to help improve workflow and communication during transitions of care. We Thought We Had More Time: Exploring Next-of-Kin Accounts of Hospice and Palliative Care Discussions for Veterans Who Died in VA Medical Centers (S766) Beverly Williams, PhD, University of Alabama at Birmingham, Birmingham, AL. F. Amos Bailey, MD, University of Alabama at Birmingham/Birmingham VA Medical Center, Birmingham, AL. Lesa Woodby, PhD MPH, Birmingham VA Medical Center, Birmingham, AL. Angelina Wittich, PhD MPH, Birmingham VA Medical Center, Birmingham, AL. Kathryn Burgio, PhD, University of Alabama at Birmingham, Birmingham, AL. (All authors listed above had no relevant financial relationships to disclose.)