Improving processes of hospital care during the last hours of life

Background: Known for excellence in care in the last days and hours of life, hospice programs can help individuals have a good death and lead to higher family satisfaction with quality of care. Our objective was to evaluate the effectiveness of a multicomponent palliative care intervention based on the best practices of home hospice and designed to improve the quality of care provided for patients dying in an acute care inpatient setting. Methods: This study was a before-after intervention trial conducted between 2001 and 2003. Participants included physician, nursing, and ancillary staff on inpatient services of an urban, tertiary care Veterans Affairs medical center. The palliative care intervention included staff education and support to identify patients who were actively dying and implement care plans guided by a comfort care order set template for the last days or hours of life. Data abstracted from computerized medical records of 203 veterans who died during a 6-month period before (n = 108) and after (n = 95) intervention were used to determine the impact of intervention on symptom documentation and 5 process of care indicators. Results: There was a significant increase in the mean (SD) number of symptoms documented from 1. 7 (2.1) to 4.4 (2.7) (P < .001), and the number of care plans increased from 0.4 (0.9) to 2.7 (2.3) (P < .001). Opioid medication availability increased from 57.1% to 83.2% (P < .001), and do-not-resuscitate orders increased from 61.9% to 85.1% (P < .001). There were nonsignificant changes in the proportion of deaths that occurred in intensive care units (P =. 17) and in the use of nasogastric tubes (P =. 40), and there was a significant increase in the use of restraints (P < .001). Conclusion: Our results indicate that end-of-life care improved after the introduction of the palliative care program.