End-of-life care pathways in acute and hospice care: an integrative review

CONTEXT

Over the past decade, there has been widespread adoption of end-of-life care pathways as a tool to better manage care of the dying in a variety of care settings. The adoption of various end-of-life care pathways has occurred despite lack of robust evidence for their use.

OBJECTIVES

This integrative review identified published studies evaluating the impact of an end-of-life care pathway in the acute and hospice care setting from January 1996 to April 2010.

METHODS

A search of the electronic databases Scopus and Cumulative Index of Nursing and Allied Health Literature as well as Medline and the World Wide Web were undertaken. This search used Medical Subject Headings key words including "end-of-life care," "dying," "palliative care," "pathways," "acute care," and "evaluation." Articles were reviewed by two authors using a critical appraisal tool.

RESULTS

The search revealed 638 articles. Of these, 26 articles met the inclusion criteria for this integrative review. No randomized controlled trials were reported. The majority of these articles reported baseline and post implementation pathway chart audit data, whereas a smaller number were local, national, or international benchmarking studies. Most of the studies emerged from the United Kingdom, with a smaller number from the United States, The Netherlands, and Australia.

CONCLUSION

Existing data demonstrate the utility of the end-of-life pathway in improving care of the dying. The absence of randomized controlled trial data, however, precludes definitive recommendations and underscores the importance of ongoing research.

Code status orders and goals of care in the medical ICU

BACKGROUND

Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care.

METHODS

We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders.

RESULTS

Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care.

CONCLUSIONS

Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.

Care goals and decisions for children referred to a pediatric palliative care program

OBJECTIVE

To describe goals of care for children with complex, life-limiting conditions and to assess the variables that may influence these goals.

METHODS

Goals of care were elicited from the parents and children with complex, life-limiting conditions during initial palliative care consultation. Data abstracted included: diagnoses, demographics, time from diagnosis until initial palliative care consult, spirituality status, resuscitative status, and disposition at discharge. Goals of care were categorized into one of four quality-of-life domains: 1) physical health and independence, 2) psychological and spiritual, 3) social, and 4) environment. Summary statistics were prepared and comparisons were made between the four categories of goals. Descriptive statistics were utilized to explore potential associations with a decision to pursue full medical support.

RESULTS

One hundred and forty goals of care were obtained from 50 patients/parents. The median patient age was 4.6 years. Thirty-seven patients had significant cognitive delay/impairment. Neuromuscular disorders accounted for more than half of the diagnoses. Forty-nine patients identified at least one goal pertaining to physical health and independence. This was significantly more than any other category (p < 0.0001). Thirty-three of the 50 patients (66%) opted for full medical support at the time of initial consult.

CONCLUSIONS

Children with complex, life-limiting conditions and their families referred to a palliative care service commonly verbalize goals related to health maintenance and independence. Anticipating this expectation may foster communication and improve patient care.

Mapping hospice patients' perception and verbal communication of end-of-life needs: an exploratory mixed methods inquiry

BACKGROUND

Comprehensive "Total Pain" assessments of patients' end-of-life needs are critical for providing improved patient-clinician communication, assessing needs, and offering high quality palliative care. However, patients' needs-based research methodologies and findings remain highly diverse with their lack of consensus preventing optimum needs assessments and care planning. Mixed-methods is an underused yet robust "patient-based" approach for reported lived experiences to map both the incidence and prevalence of what patients perceive as important end of life needs.

METHODS

Findings often include methodological artifacts and their own selection bias. Moving beyond diverse findings therefore requires revisiting methodological choices. A mixed methods research cross-sectional design is therefore used to reduce limitations inherent in both qualitative and quantitative methodologies. Audio-taped phenomenological "thinking aloud" interviews of a purposive sample of 30 hospice patients are used to identify their vocabulary for communicating perceptions of end-of-life needs. Grounded theory procedures assisted by QSR-NVivo software is then used for discovering domains of needs embedded in the interview narratives. Summary findings are translated into quantified format for presentation and analytical purposes.

RESULTS

Findings from this mixed-methods feasibility study indicate patients' narratives represent 7 core domains of end-of-life needs. These are (1) time, (2) social, (3) physiological, (4) death and dying, (5) safety, (6) spirituality, (7) change & adaptation. The prevalence, rather than just the occurrence, of patients' reported needs provides further insight into their relative importance.

CONCLUSION

Patients' perceptions of end-of-life needs are multidimensional, often ambiguous and uncertain. Mixed methodology appears to hold considerable promise for unpacking both the occurrence and prevalence of cognitive structures represented by verbal encoding that constitute patients' narratives. Communication is a key currency for delivering optimal palliative care. Therefore understanding the domains of needs that emerge from patient-based vocabularies indicate potential for: (1) developing more comprehensive clinical-patient needs assessment tools; (2) improved patient-clinician communication; and (3) moving toward a theoretical model of human needs that can emerge at the end of life.

Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care

Workforce shortages, late referrals, and palliative care program resource constraints present significant barriers to meeting the needs of hospitalized patients facing serious illnesses. The Center to Advance Palliative Care convened a consensus panel to select criteria by which patients at high risk for unmet palliative care needs can be identified in advance for a palliative care screening assessment. The consensus panel developed primary and secondary criteria for two checklists-one to use for screening at the time of admission and one for daily patient rounds. The consensus panel believes that by implementing a checklist approach to screening patients for unmet palliative care needs, combined with educational initiatives and other system-change work, hospital staff engaged in day-to-day patient care can identify a majority of such needs, reserving specialty palliative care services for more complex problems.

Goals of Care among Hospitalized Patients: A Validation Study

Our objective was to validate 6 literature-derived goals of care by analyzing open-ended and closed-ended responses about goals of care from a previous study of hospitalized patients. Eight clinicians categorized patients’ open-ended articulations of their goals of care using a literature-derived framework and then compared those categorizations to patients’ own closed-ended selections of their most important goal of care. Clinicians successfully categorized patients’ open-ended responses using the literature-derived framework 83.5% of the time, and their categorizations matched patients’ closed-ended most important goal of care 87.8% of the time. Goals that did not fit within the literature-derived framework all pertained to the goal of understanding a patient’s diagnosis or prognosis; this seventh potential goal can be added to the literature-derived framework of 6 goals of care.

Decisions at the end of life: have we come of age?

Decision making is a complex process and it is particularly challenging to make decisions with, or for, patients who are near the end of their life. Some of those challenges will not be resolved - due to our human inability to foresee the future precisely and the human proclivity to change stated preferences when faced with reality. Other challenges of the decision-making process are manageable. This commentary offers a set of approaches which may lead to progress in this field. One clearly desirable approach can and should be used more often than it is: the routine inclusion of discussions about the goals of care and documentation with all patients who have a poor prognosis. The match between a patient's goals and the care received should be the gold standard for quality palliative care.Planning for future situations is necessary but hard. In order to achieve efficient elicitation and documentation of advance care planning, research is needed on each individual's thresholds for transitioning from curative to palliative intent and on the trajectory of changed preferences when illness occurs. Another clearly desirable approach is the documentation and use of community preferences, so that proxies making decisions without guidance from the patient can at least know what the majority of people considering similar situations chose to do.Part of the challenge of achieving 'quality dying' may have to do with the still current (mainly Western) tendency to a death-denying culture and the inability of dying people to enter into the dying role. Awareness of the tasks of the dying role and the provision of time and space for those tasks during the delivery of medical care is essential. Medicine needs to continue to enhance the existential maturity of our profession, our patients and the cultures in which we practice. This state of mind should provide for decisions made with a more settled acceptance of mortality and with more awareness of the necessary connection to our survivors and next generation that mortality creates. Specific interventions, such as Dignity Therapy and advance care planning, may aid this state of mind.

Perceptions of terminally ill patients and family members regarding home and hospice as places of care at the end of life

To enable demand-based palliative care, it is important to know the perceptions of terminally ill patients and their family members regarding home and hospice as places of care at the end of life. Eight women and five men suffering from cancer and with a life expectancy of 3 months or less were interviewed. In each case one of the family members was also interviewed. Four patients spent their last phase of life at home, nine in a hospice. This paper provides further insight in the patient perspective in palliative care. The results reveal that a cohabiting partner seems an important prerequisite for terminally ill patients to stay at home. For spouses it is an obvious choice to facilitate the patients' stay at home, even when it becomes too demanding, something not discussed between spouse and patient. When sufficient care at home seems impossible and the negotiation between patients and family members results in the opinion that living at home is no longer an option, it is decided that the patient moves to a hospice. The choice for the specific setting of the patients' new residence seems to be random; one possibility is pointed out to them and seems appropriate.

Family caregivers, patients and physicians: ethical guidance to optimize relationships

Family caregivers play a major role in maximizing the health and quality of life of more than 30 million individuals with acute and chronic illness. Patients depend on family caregivers for assistance with daily activities, managing complex care, navigating the health care system, and communicating with health care professionals. Physical, emotional and financial stress may increase caregiver vulnerability to injury and illness. Geographically distant family caregivers and health professionals in the role of family caregivers may suffer additional burdens. Physician recognition of the value of the caregiver role may contribute to a positive caregiving experience and decrease rates of patient hospitalization and institutionalization. However, physicians may face ethical challenges in partnering with patients and family caregivers while preserving the primacy of the patient-physician relationship. The American College of Physicians in conjunction with ten other professional societies offers ethical guidance to physicians in developing mutually supportive patient-physician-caregiver relationships.

Dementia, goals of care, and personhood: a study of surrogate decision makers' beliefs and values

Surrogate decision makers for persons with advanced dementia play a key role in making decisions about medical treatments for their loved ones. We conducted in-depth interviews of 20 surrogates to examine their goals of care preferences and beliefs about personhood. All surrogates believed the goal of comfort was important, and 30.0% believed that curing physical problems was important. Significant proportions of surrogates acknowledged dementia-related changes in patients' ability to reason, communicate, and relate to others. Qualitative findings demonstrated diverse beliefs regarding the impact of dementia on factors related to personhood, for example, dignity, respect from others, and having a life worth living. In conclusion, the surrogates we interviewed expressed diverse preferences regarding goals of care and diverse assessments about the impact of dementia on personhood.

Cultural beliefs about a patient's right time to die: an exploratory study

BACKGROUND

Generalist physicians must often counsel patients or their families about the right time to die, but feel ill-prepared to do so. Patient beliefs may help guide the discussions.

OBJECTIVE

Because little prior research addresses such beliefs, we investigated them in this exploratory, hypothesis-generating study.

DESIGN AND SUBJECTS

Anticipating culture as a key influence, we interviewed 26 Mexican Americans (MAs), 18 Euro-Americans (EAs), and 14 African Americans (AAs) and content-analyzed their responses.

MAIN RESULTS

Nearly all subjects regardless of ethnic group or gender said God determines (at least partially) a patient's right time to die, and serious disease signals it. Yet subjects differed by ethnic group over other signals for that time. Patient suffering and dependence on "artificial" life support signaled it for the MAs; patient acceptance of death signaled it for the EAs; and patient suffering and family presence at or before the death signaled it for the AAs. Subjects also differed by gender over other beliefs. In all ethnic groups more men than women said the time of death is unpredictable; but more women than men said the time of death is preset, and family suffering signals it. Furthermore, most MA women--but few others--explicitly declared that family have an important say in determining a patient's right time to die. No confounding occurred by religion.

CONCLUSIONS

Americans may share some beliefs about the right time to die but differ by ethnic group or gender over other beliefs about that time. Quality end-of-life care requires accommodating such differences whenever reasonable.