Timothy J. Keay

Indicators of quality medical care for the terminally ill in nursing homes

PURPOSE: To identify medical care indicators for nursing home terminal care.

Nursing Home Physician Educational Intervention Improves End-of-Life Outcomes

CONTEXT Nursing homes are the setting for one of five deaths in the United States. Unfortunately these deaths are often accompanied by pain and symptoms of discomfort. OBJECTIVE To determine if an educational intervention designed for nursing home physicians improves the quality of dying for nursing home residents. DESIGN Prospective measurement of changes in end-of-life medical care indicators. INTERVENTION Half-day adult educational outreach program, including audit and feedback, targeted at opinion leaders, and quality improvement suggestions. SETTING Five geographically diverse Maryland skilled nursing facilities with a total of 654 beds. PARTICIPANTS The terminal care delivered by 61 physicians who cared for 203 dying residents in the 5 facilities was reviewed. An intervention was targeted to medical directors and those physicians with the majority of patients. Twelve physicians participated in the educational program. MAIN OUTCOME MEASURES Chart documentation of recognition of possible death, presence of advance directives, pain control, analgesics used, dyspnea control, control of uncomfortable symptoms during the dying process, documented hygiene, documented bereavement support, and total patient comfort. RESULTS The four nursing facilities that completed the intervention all had significant improvements in end-of-life care outcomes (p < 0.001, chi2). No statistically significant changes were found in any measure in the cohort nursing facility that did not complete the intervention. When we compared residents with hospice services to those without, we found significant increases in documentation of better hygiene, bereavement support, and total patient comfort (p < 0.001, chi2 for each). CONCLUSIONS Important terminal care outcomes can be significantly improved by targeting key nursing home physicians with an adult educational program that includes audit and feedback, and quality improvement suggestions.

Incorporating education on palliative care into the long-term care setting

Approximately one‐third of all Americans will pass through a long‐term care facility before they die, and many who require palliative care will reside there during the final weeks and months of their lives. In order to address this need, the unique characteristics of long‐term care facilities are outlined, and the incentives for all levels of academic institutions to offer education in that setting are presented.

The case for hospice care in long-term care environments.

Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.

Required training in hospice and palliative care at the University of Maryland School of Medicine

BACKGROUND Over a period of four years the authors developed and integrated into the curriculum of their medical school training programs in palliative medicine. Critical required elements in the freshman year focus on attitudes and the physicians role in the care of terminally ill patients and their families. A 16-hour module has been designed to be a required element for junior students. It includes in-depth classroom and experiential training in palliative medicine. The results of the pilot of this module are presented. METHODS The module consisted of one four-hour half-day session for four consecutive weeks during the ambulatory block in internal medicine. The first half-day class included both lectures and small-group discussions. Pain management, management of non-pain symptoms, and recognition of and basic interventions in spiritual and psychosocial suffering were covered. Required out-of-classroom reading assignments were distributed. The second and third half days were experiential, during which the student, in the company of a hospice nurse, made palliative care evaluations of terminally ill hospice patients. The last half day was a classroom session where the students presented their palliative care plan(s) for the patient(s) they had encountered on half days 2 and 3 to an interdisciplinary team (IDT) of the other students, a hospice medical director, a social worker, a hospice nurse, and a chaplain. Student scores on a 60-item objective test and participation in the IDT meeting were the primary data sources used to evaluate student achievement of the course objectives. RESULTS AND CONCLUSIONS The majority of students attained the course objectives. Student evaluations of the module were very positive, particularly with regard to the home visits and the need for this training. It is anticipated that the module will be required during the 1999-00 academic year, with each students performance contributing to his or her final grade in junior medicine.

Assessing Medical Care of Dying Residents in Nursing Homes

Although approximately one of five people in the United States die in nursing homes (NHs), little has been written about their quality of dying, including the quality of terminal medical care. The purpose of this study is to review actual medical practices in NHs to suggest factors important for delivering good quality terminal care. Four NHs were surveyed for management of residents who died in 1992. A convenience sample of charts of newly admitted and longer term residents were abstracted for demographic variables, death, diagnostic categories, and various laboratory and other parameters. Charts of those residents who died were further reviewed using indicators of quality medical care, such as presence of advance directives, control of pain, and control of dyspnea, based upon recent published clinical practice guidelines for terminal care in NHs. Three hundred and seventy-one charts were abstracted. Forty-one charts documented the residents death. We found that NHs without regulatory difficulties usually had expected deaths that were managed appropriately as measured by terminal medical care quality indicators. NHs with a history of regulatory difficulties had a higher prevalence of residents who died suddenly and unexpectedly, often with problems in the quality of care as measured by the same indicators. There was a correspondence between physician certification, antemortem diagnosis of terminal illness, and appropriate terminal care. We conclude that physicians are able to recognize impending death and redirect the medical care of dying NH residents toward goals of terminal care management. This is more likely to occur in a NH environment that places greater emphasis upon total quality management. We suggest that another indicator in providing good NH terminal care is the physicians performance in predicting a short life expectancy.

Ethical Concerns About Relapse Studies

It is universally accepted that informed consent to participate in medical research should be given by subjects. People have the fundamental human right to freely choose, without coercion or withholding of information necessary to make a reasonable choice, whether they will undergo any risks associated with a research project. United States researchers have known for some time that they have the duty to inform potential subjects of the nature of proposed research and the risks and possible benefits, and to seek consent. Investigators also have the duty to design the research so that it will be scientifically valid while minimizing foreseeable and avoidable harms.

Palliative Surgical Oncology

Palliative surgical oncology is a relatively new concept, but builds on a long tradition in surgery. As the field of palliative medicine grows and becomes its own specialty, surgeons have been receiving some specialized training in palliative care; devising specific palliative surgical procedures; and reevaluating the ethics of their interactions with patients, especially for the selection of palliative surgical procedures. This is leading to a new form of surgical practice in which the emphasis is on relief of present or anticipated symptoms, even if the interventions do not prolong a patients life span.

Creative solution for implementation of experiential, competency-based palliative care training for internal medicine residents.

To graduate internal medicine residents with basic competency in palliative care, we employ a two-pronged strategy targeted at both residents and attending physicians as learners. The first prong provides a knowledge foundation using web-based learning programs designed specifically for residents and clinical faculty members. The second prong is assessment of resident competency in key palliative care domains by faculty members using direct observation during clinical rotations. The faculty training program contains Competency Assessment Tools addressing 19 topics distributed amongst four broad palliative care domains designed to assist faculty members in making the clinical competency assessments. Residents are required to complete their web-based training by the end of their internship year; they must demonstrate competency in one skill from each of the four broad palliative care domains prior to graduation. Resident and faculty evaluation of the training programs is favorable. Outcome-based measures are planned to evaluate long-term program effectiveness.

Review of Medical Care in Cited Nursing Homes: Key Areas of Deficiency

This article identifies key areas of physician performance in nursing homes (NHs) cited by state regulators. Six faculty members of the University of Maryland Department of Family Medicine reviewed medical care in ten Maryland NHs, which constituted 6.7% of Marylands Comprehensive-level beds, with a sample of 547 charts and 81 physicians. The reviewers recorded the absence of expected minimum standards of performance in patient care. Nine of the NHs had been cited and one was anticipating an audit by state regulators. Citation by regulators corresponded with inadequate documentation of patient history and physical examinations, especially of neurologic conditions; with inadequate health care maintenance; with mismanagement of laboratory findings such as bacteriuria; and with lack of medical administrative leadership and quality management. These key areas of physician performance should be regularly assessed or systematically changed in all NHs to maintain at least minimum standards of care.