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.

The challenge of providing spiritual care

Spirituality is an essential element of holistic nursing and nurses need the knowledge and confidence to address spiritual issues with patients. This paper describes the development of a tool to help with broaching this sensitive aspect of care. It argues that nurses need to examine their own spiritual needs in order to be able to help others.

A competency model for the assessment and delivery of spiritual care

The delivery of spiritual and religious care has received a high profile in national reports, guidelines and standards since the start of the millennium, yet there is, to date, no recognized definition of spirituality or spiritual care nor a validated assessment tool. This article suggests an alternative to the search for a definition and assessment tool, and seeks to set spiritual care in a practical context by offering a model for spiritual assessment and care based on the individual competence of all healthcare professionals to deliver spiritual and religious care. Through the evaluation of a pilot study to familiarize staff with the Spiritual and Religious Care Competencies for Specialist Palliative Care developed by Marie Curie Cancer Care, the authors conclude that competencies are a viable and crucial first step in 'earthing' spiritual care in practice, and evidencing this illusive area of care.

Spirituality in health: the role of spirituality in critical care

Caring for critically ill patients requires that physicians and other health care professionals recognize the potential importance of spirituality in the lives of patients, families, and loved ones and in their own lives. Patients and loved ones undergo tremendous stress and suffering in facing critical illness. Professional caregivers also face similar stress and sadness. Spirituality offers people away to understand suffering and illness. Spiritual beliefs can also impact how people cope with illness. By addressing spiritual issues of patients, loved ones, and ourselves, we can create more holistic and compassionate systems of care.

Cultural Diversity in Pastoral Care

Fukuyama and Sevig are counseling psychologists who have a particular interest in the integration of spirituality into multicultural counseling and training. In this article the authors address the complexity of integrating religious and cultural diversity and spirituality into chaplaincy care in the context of an increasingly diverse society. By posing a series of questions, the authors systematically clarify definitions and meanings of culture, spirituality, cultural diversity and multiculturalism, multicultural and spiritual competencies in counseling, and ethical considerations. The authors discuss clinical applications in the context of a "spirituality and health movement," and provide suggestions for continuing professional development. The authors support the notion that multicultural engagement is spiritually synergistic, and encourage health care providers to communicate across professional disciplines to broaden and enrich discourse on these topics.

The Search for Spiritual/Cultural Competency in Chaplaincy Practice: Five Steps that Mark the Path

Chaplains who are clinically trained and certified spiritual care professionals can make a unique contribution in today's increasingly pluralistic and global health care context with diverse religious, spiritual and cultural values, beliefs and practices. The author characterizes this contribution as spiritual/cultural competency. A self-defined web of meaning is unique to each person, comprised of a composite of values and beliefs, a fabric woven by way of one's life narrative. The proven approach of clinical learning, with heightened introspective and interpersonal awareness, serves as the chaplain's primary pathway to multi-spiritual/cultural competency, integrated with the exploration of context in a way not prioritized before. Utilizing sources from pastoral theology, anthropology and multicultural counseling, a five-step process of competency assessment is introduced and discussed with the aid of two cases. Knowing one's own spiritual/cultural grounding is the first step in this open-ended search.

Religious maturity in the midst of death and dying

Healthy religious experience is defined by certain qualities of expression. In an effort to explore the concept of mature religious phenomenology, this article includes descriptions of two encounters from personal pastoral experience. The first encounter shows how a person with an unhealthy religious experience faces death. The second encounter describes an expression of mature religious experience in the face of death and how a pastoral caregiver can facilitate its outcome. This is followed by a pastoral theological response.

In the world but not of the world: going beyond a dilemma

Is the issue addressed in this volume a question like "What time is it?" or a quest-ion like "What is time?" I argue that it is a quest-ion that requires professional chaplaincy to quest for an answer although it will always have blurred edges that lack succinctness, clarity, and certainty. The challenge posed by the quest-ion means that we must transform the dilemma into a higher synthesis that respects the qualitative aspects inherent in the profession.

Addressing patients' emotional and spiritual needs

BACKGROUND

A comprehensive, systematic literature review and original research were conducted to ascertain whether patients' emotional and spiritual needs are important, whether hospitals are effective in addressing these needs, and what strategies should guide improvement.

METHODS

The literature review was conducted in August 2002. Patient satisfaction data were derived from the Press Ganey Associates' 2001 National Inpatient Database; survey data were collected from 1,732,562 patients between January 2001 and December 2001.

RESULTS

Data analysis revealed a strong relationship between the "degree to which staff addressed emotional/spiritual needs" and overall patient satisfaction. Three measures most highly correlated with this measure of emotional/spiritual care were (1) staff response to concerns/complaints, (2) staff effort to include patients in decisions about treatment, and (3) staff sensitivity to the inconvenience that health problems and hospitalization can cause.

DISCUSSION

The emotional and spiritual experience of hospitalization remains a prime opportunity for QI. Suggestions for improvement include the immediate availability of resources, appropriate referrals to chaplains or leaders in the religious community, a team dedicated to evaluating and improving the emotional and spiritual care experience, and standardized elicitation and meeting of emotional and spiritual needs. Survey data suggested a focus on response to concerns/complaints, treatment decision making, and staff sensitivity.

Pastoral care in a time of global market capitalism

The author defines pastoral theology as "the study of the micro-world of intrapsychic and interpersonal interactions with the tools of theology and the social sciences for the purpose of support and healing. In a typical class or supervisory session, we analyze the words, voice inflection, pace, and gestures of an intimate conversation between two people, looking for clues to the deep structure of personality and intimate relationships. The hope of such study is that we will see the revelation of God is love and power in action to validate and challenge the theological traditions that give us eyes to see and invite us to see more clearly."

How satisfied are patients with the ministry of chaplains?

The author describes the importance of chaplaincy departments conducting periodic patient satisfaction studies and provides quantitative results from 1440 patients discharged from one of 14 U.S. general hospitals. Patients expressed the most satisfaction in response to the item, "The chaplain seemed to be a person of spiritual sensitivity." The results also suggest the characteristics of patients who appear most responsive to this ministry.