Scott Shreve

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.

Barriers and strategies to an iterative model of advance care planning communication.

Background: Early and repeated patient–provider conversations about advance care planning (ACP) are now widely recommended. We sought to characterize barriers and strategies for realizing an iterative model of ACP patient–provider communication. Methods: A total of 2 multidisciplinary focus groups and 3 semistructured interviews with 20 providers at a large Veterans Affairs medical center. Thematic analysis was employed to identify salient themes. Results: Barriers included variation among providers in approaches to ACP, lack of useful information about patient values to guide decision making, and ineffective communication between providers across settings. Strategies included eliciting patient values rather than specific treatment choices and an increased role for primary care in the ACP process. Conclusions: Greater attention to connecting providers across the continuum, maximizing the potential of the electronic health record, and linking patient experiences to their values may help to connect ACP communication across the continuum.

End-of-Life Nursing Education Consortium (ELNEC)–For Veterans: An Educational Project to Improve Care for All Veterans With Serious, Complex Illness

Because only 4% of veterans die in Veterans Affairs (VA) facilities, the Department of Veterans Affairs Hospice and Palliative Care Program partnered with the End-of-Life Nursing Education Consortium (ELNEC) to develop veteran-specific curricula and train-the-trainer courses. The goal was to educate and empower nurses to improve care for all veterans with serious illnesses. The partnership resulted in the development of 2 curricula that were disseminated through 6 national train-the-trainer courses. More than 730 participants attended, representing VA facilities and community providers from all 50 states and Puerto Rico and the District of Columbia. Since the training, 72 ELNEC–For Veterans courses have been offered in VA facilities and 17 courses in community settings. Attendees have taken what they have learned to promote palliative care education in their own facilities, help to change systems of care, collaborate with other institutions, develop bereavement services, and promote self-care for staff caring for dying veterans. With the funding for the initiative complete, the attendance and commitment of nurses and multiple other disciplines from within VA and community agencies highlight the importance of the ELNEC–For Veterans curriculum and education. Although they are aware of many barriers, their commitment to provide this education either “live” or through online education has been stellar. While the funding from the VA for this project has ceased, nurses have been provided a plethora of resources to be used to improve care for all veterans and their families. A change of culture has begun, as nurses have been educated to promote and advocate for excellent palliative care for all veterans.

The Use of Toolkits for Palliative Care Quality Improvement: The VA's “Strive for 65 Implementation Package” (SA500)

with the highest potential for impact upon the field of hospice and palliative medicine. A hand search of leading journals highly relevant to the practice of hospice and palliative care was supplemented with a search of evidencebased reviews, a targeted keyword search, and conversations with experts in the disciplines of medicine, nursing, and social work. Journal articles were reviewed for both study quality and potential for immediate impact on the field of hospice and palliative care. There was a selection bias against descriptive studies, pilot studies, pre-clinical studies, retrospective studies, open-label trials, case-series, instrument validation studies, and confirmatory analyses.