Intervention to Improve Care at Life's End (BEACON)

• Chart review 1. Presence of order for opioid pain medication at time of death 2.Do Not Resuscitate order present 3.Location of death (ICU vs. other) 4.Presence of nasogastric tube or intravenous line 5.Presence of restraints at or near time of death [ Time Frame: Time of death ] [ Designated as safety issue: No ]
  

• Symptoms/care plans, advance directives, resuscitations, hospice care, palliative consults, presence of family, pastoral services, info on hospital stay, locations of care. [ Time Frame: For primary analysis of each outcome, 12 months before and 12 months after 6-month intervention period ] [ Designated as safety issue: No ]
  
• After-death interviews of family on attitudes, perceptions & satisfaction w/care [ Time Frame: For primary analysis of each outcome, 12 months before and 12 months after 6-month intervention period ] [ Designated as safety issue: No ]
  

Background:

At life's end, most people experience physical suffering, as well as significant emotional, spiritual, and social distress. Often, patients are not recognized as actively dying. Suffering may be exacerbated by usual medical care, in which aggressive, futile, or iatrogenically harmful treatments frequently are continued. During this time, palliative care treatment plans have the potential to improve quality of end-of-life care and reduce hospital costs. Despite the benefits of palliative care, it is not routinely available in inpatient settings without designated hospice units. Most individuals are likely to die in a hospital or nursing home, creating a compelling need to address processes of care for actively dying patients in inpatient settings. The "Best Practices for End-of-Life Care for Our Nations' Veterans" (BEACON) trial, was a multi-center implementation-facilitation trial of an intervention to improve the quality of end-of-life care in VA Medical Centers (VAMCs).

Objectives:

The primary aim of this study was to evaluate the effectiveness of a multi-component intervention for improving processes of care provided in the last days of life in VAMCs.

The second aim was to conduct after-death interviews with next-of-kin and qualitative analysis of their perceptions of the care provided to the veteran and family.

Methods:

The BEACON study was a real-world, pre-post implementation trial in six VAMCs. The 4-month, multi-modal intervention targeted VAMC inpatient providers, including physician, nursing, and ancillary staff. It consisted of preparatory site visits, a staff training program, a newly developed Comfort Care Order et decision support tool built into the CPRS, and follow-up consultation. The intervention team travelled to each site to conduct two weeks of comprehensive in-service training. Staff were trained to identify actively-dying patients and implement a set of best practices of traditionally home-based hospice care for dying patients. The team provided assistance with policies, procedures, and skill training needed to implement comfort care interventions.

To control for secular trends, introduction of the intervention at each VAMC was staggered across time at six-month intervals using a multiple-baseline, stepped wedge design. Data on processes of end-of-life care (last 7 days) were abstracted from the CPRS medical records of all veterans who died before, during, and after the intervention (January 2005-February 2011).

A priori, five processes of care were identified as primary endpoints to indicate quality of end-of-life care: 1) presence of an order for opioid pain medication at time of death; 2) a do-not- resuscitate (DNR) order in place at time of death; 3) location of death; 4) presence of enteral feeding tube or intravenous line at time of death; and 5) physical restraints in place at or near time of death.

Status:

The results of the trial were presented at the European Association for Palliative Care. The primary analyses have been completed and the main manuscript will be submitted in December 2012 for publication. Interviews have been conducted with key informants to describe uptake of the intervention and a formative analysis is underway. The team will continue to analyze both quantitative and qualitative data for future publication.