Nurses’ Perceptions of Medication Use at the End of Life in an Acute Care Setting:

Impact of a Nurse-Driven Opioid Titration Protocol on Quality of Orders at End of Life

At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

An Innovative Application of End-of-Life Nursing Education Consortium Curriculum to Increase Clinical Nurses' Palliative Care Knowledge

Clinical nurses are in a crucial position to provide primary palliative care by advocating for patients and families at the end of life, collaborating with the health care team to optimize quality of life, and contributing to enhanced symptom management. Most clinical nurses, however, have not received the comprehensive palliative care education needed to provide high-quality palliative care. The End-of-Life Nursing Education Consortium curriculum can bridge this gap by providing nurses with the knowledge needed to promote palliative care. Following completion of an End-of-Life Education Consortium train-the-trainer program, 6 nurses from a large, metropolitan academic medical center designed and implemented a series of 20-minute educational sessions informed by a hospital-wide needs assessment and based on the End-of-Life Nursing Education Consortium curriculum. The educational sessions, Palliative Care Conversations, provide clinical nurses with the core palliative care knowledge and skills needed to advocate for and provide patient-/family-centered care throughout the serious illness trajectory and at end of life. This article describes the process, design, and content of the palliative care educational sessions.