Hospitals, nursing homes can learn much from hospice care

THERE is much value in training hospital and nursing home staff in the basics of palliative care to make the last days of a dying patient's life as comfortable and dignified as possible. So says F. Amos Bailey of the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham in the US. Bailey is the leader of a study [1] that saw the benefits of introducing palliative care strategies, typical of hospices, within the setting of Veterans Affairs Medical Centers. Although conducted with US veterans in mind, their findings can have a wider impact, as most Americans will eventually die within the inpatient setting of a hospital or nursing home. The study appears in the Journal of General Internal Medicine [2], published by Springer.

The Best Practices for End-of-Life Care for Our Nations' Veterans (BEACON) trial was conducted at six Veterans Affairs Medical Centers, where over 1,620 staff members received training in various processes of care relevant to the dying. It aimed to test the value of introducing such processes of care within the inpatient setting of a hospital or a medical center to ease the end-of-life experience of dying patients and their families.
The multi-component intervention included training hospital staff on how to identify dying patients, how to communicate the prognosis to patients and families, and how to 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 by hospital staff.
The research group found that this broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care. These include more orders for opioid medication for pain and shortness of breath, antipsychotic and benzodiazepine medications for delirium, agitation and anxiety as well as medications for rattling breathing, sometimes known as a death rattle. The removal of nasogastric tubes and the presence of advance directives (for example a living will) also highlighted the value of a more comprehensive plan that pre-empts and decreases the anticipated distress of patients and families in the last hours of life.
The results of the BEACON trial indicate the strategy's potential for greater dissemination to improve end-of-life care for the thousands of patients who die each year in inpatient settings.
"We only die once, and therefore there is only one opportunity to provide excellent care to a patient in the last days of life," writes Bailey and colleagues. "The keys to excellent end-of-life care are recognizing the imminently dying patient, communicating the prognosis, identifying goals of care, and anticipating and palliating symptoms. Since it is not possible to predict with certainty which symptoms will arise, it is prudent to have a flexible plan ready."

[1] Bailey, F.A. et al (2013) Intervention to Improve Care at Life's End in Inpatient Settings: The BEACON Trial, Journal of General Internal Medicine. DOI 10.1007/s11606-013-2724-6
[2] The Journal of General Internal Medicine is the official journal of the Society of General Internal Medicine.