Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial
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Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.
To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.
Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.
Six Veterans Affairs Medical Centers (VAMCs).
Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.
Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.
Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.
This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.
KEY WORDSpalliative care end-of-life care palliative medicine hospice inpatient
The authors thank the participating VAMCs, their Palliative Care Consultation Teams, and chaplains, including: Anna D. Senseney, MD (Site Principal Investigator), Karen Lukacs, RN, APN, and the Palliative Care Team at the Ralph H. Johnson VAMC, Charleston, SC; Adam Herman, MD, Orania Tigaieru, MD, Donna Lewis, CRNP, and the Palliative Care Team at the Atlanta VAMC, Decatur, GA; Debra Layer, CRNP, and the Palliative Care Team at the William Jennings Bryan Dorn VAMC, Columbia, SC; Michael Willoughby, MD, and the Palliative Care Teams at the Charlie Norwood VAMC, Augusta GA, the Malcom Randall VAMC, Gainesville, FL, and the G.V. Sonny Montgomery VAMC, Jackson, MS.
We also thank Rosie Durham, RN, MSN, for assistance with study implementation, Stacey Kovacs, PhD, and Jane E. Castle PhD, RN, for assistance in study design, Janice Taylor, RN, MSN, for chart abstraction, Sandra Broeren, MD, for training assistance, Jean Marie White, BA, for project coordination, and Angelina Wittich, PhD, for assistance with manuscript preparation.
This research was supported by a Merit Review grant from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Service (IIR 03-126 “Intervention to Improve Care at Life’s End in VA Medical Centers;” PI: KL Burgio, Co-PI: FA Bailey). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript.
ClinicalTrials.gov identifier: NCT00234286
This study was presented at the Annual Meeting of the European Association of Palliative Care, Trondheim, Norway, June 2012.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Conflict of interest
The authors declare that they do not have a conflict of interest.
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