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Study: Bring home-based hospice techniques to hospital

Monday February 17, 2014
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Using home-based hospice practices for terminally ill, hospitalized patients could reduce suffering and improve end-of-life care, according to a study.

The study, published Jan. 21 on the website of the Journal of General Internal Medicine, was described as the first to show that palliative care techniques usually used in a home setting can affect end-of-life care for those who die in a hospital.

The study “was designed to see whether home-based hospice practices could be successfully integrated into care in hospitals to improve the end-of-life experience for those who remain hospitalized at time of death,” Amos Bailey, MD, of the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham, said in a news release.

The study, Best Practices for End-of-Life Care for Our Nation’s Veterans, or BEACON, was conducted at six VA medical centers and included more than 6,000 patients between 2005 and 2011.

The multicomponent intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients and families and implement best practices of traditionally home-based hospice care in the inpatient setting. The intervention was supported by an electronic order set — called a comfort care order set — and other educational tools to prompt and guide implementation.

BEACON examined several variables such as orders and use of medications for pain or confusion. It encouraged a more homelike environment, such as by allowing the family to stay with their loved one or patients to eat some of their favorite foods and drinks. It suggested less emphasis on the use of bedside monitoring and invasive procedures.

The study developed a screening tool for healthcare professionals to better assess when death was imminent — within a few days or a week. The comfort care order set could then be added to the patient’s treatment plan. The orders prompted medical staff to adopt typical hospice practices such as providing easier access to pain medications and allowing patients to sit up in a chair, particularly beneficial for those with heart or lung disease. If supplemental oxygen was needed, BEACON recommended its delivery through the least invasive means possible.

“We wanted an environment where the care given in the hospital was more like that available at home with hospice,” said Bailey, director of the Safe Harbor Palliative Care Program at the Birmingham VAMC and professor in the Division of Gerontology, Geriatrics and Palliative Care in the UAB School of Medicine.

The research team then created a list of measurable process outcomes to assess the effectiveness of the BEACON intervention. These outcomes included reducing ICU usage; use of appropriate medications for pain, anxiety and respiratory issues; need for restraints; and use of pastoral care or palliative care consultation.

“Every one of the 16 outcomes we measured improved after implementation of the BEACON intervention,” Kathryn Burgio, PhD, associate director for research at the Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center and professor in the UAB Division of Gerontology, Geriatrics and Palliative Care, said in the news release.

“For example, orders for pain medication increased from 62% to 73%. The percentage of patients who had IV lines or feeding tubes was lowered. The percentage who received appropriate medication for confusion or congested breathing increased. These are all variables that help ensure a less painful, less stressful and more comfortable end-of-life experience.”

Bailey said the comfort care order set is routinely used at the Birmingham VA Medical Center and the UAB Palliative and Supportive Care inpatient unit. “The BEACON protocol could be used in any hospital, and an increasing number of facilities have begun to adopt similar plans based on our findings. We have submitted a grant to expand the program into another 48 VA hospitals nationwide.”

Study abstract: http://link.springer.com/article/10.1007/s11606-013-2724-6


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