An elderly woman in cardiac arrest with multiple comorbidities is rushed into an ICU where medical teams perform numerous procedures to save her life. The patient is stabilized, but it soon becomes apparent to the medical team that although she will survive the event, her survival is only temporary.
Has anyone told the family about the patients condition? Is there an advanced directive? What is the expectation life at any cost or a peaceful death at home? Most importantly, what would the patient want?
These are the questions that can get overlooked, avoided, or confused when a patient moves from acute care to palliative care. Many times patients have not made out advanced directives or family members may not be aware that they have done so. Busy doctors may not be comfortable with or feel they have the time for lengthy discussions with the family on end-of-life care. Specialists and primary physicians may not be communicating well with each other. The result can be family confusion, isolation, resentment, or costly treatments that briefly prolong life but may be painful and not what the patient or family wanted.
Many hospitals are responding to these end-of-life issues with systems of palliative care bundles. The bundles are a collection of best practices so medical teams can partner with families to make the right care decisions at the right time for patients. The best practices include identifying patient-family preferences for treatment, improving communication between clinicians, patients, and families, incorporating social work and spiritual care, and assessing and treating pain. Ideally, the best practices are worked into rounding so crucial questions are on the minds of the entire medical team at the same time.
Patricia Murphy, APN, PhD, FAAN, an advance practice nurse in ethics and bereavement at the University of Medicine and Dentistry of New Jersey at University Hospital in Newark, is among healthcare practitioners studying the bundles effectiveness. She has been testing the bundles in the surgical ICU and in the medical ICU at University Hospital. Her teams research showed that the family meeting and its role in communication was the single biggest factor that could change outcomes in satisfaction.
Before, families had to chase after doctors to find out what was going on and would end up being talked at by different consultants, says Murphy, who specializes in ethics and bereavement at University Hospital. But when you sit down with the family and ask them what they know and start to meet them where they are, it makes an enormous difference.
Family Satisfaction Quickly RisesSusanne Walther, RN
That difference was reflected in results of a survey by Murphys research team that showed a significant difference after the bundle was introduced.
The numbers of family members satisfied with their involvement in decision making went from 12% to 69% from 2005 to 2007; their satisfaction with their understanding of information went from 44% to 73%; and the families perception of the honesty of information went from 56% to 80%, says Murphy, who also is president of the New Jersey Board of Nursing.
Other noticeable differences included decreased length of stay in the ICU and earlier withdrawal of unwanted life support.
The research showed these improvements were made with no change in the mortality rate.
The same number of people are dying were just helping them understand that sooner, says Susanne Walther, APN, who helps implement the bundles and runs the family meetings at University Hospital.
Part of the bundle involves having the do-not-resuscitate conversation with the patient earlier during treatment, perhaps even when the patient is admitted, Walther says. When family members are made aware that if the patients heart stops resuscitation would not benefit the patient, they begin to move forward and decide whether a religious leader should be contacted, whether relatives should be called home from college or taken out of a nursing home, if advanced directives are in place, and how best to use the remaining time when it is running out, Walther says.
Another key piece of the palliative care bundle is offering to connect the patient with spiritual and religious support. Even if that has not been part of the patients daily life, it may be what offers them or family members comfort in these situations, Walther says.
Costly Care Racks UpAline Holmes, RN
Excessive end-of-life treatments may not be what the family or patient wants. They also strain the nations healthcare system. A March Archives of Internal Medicine report found that one-third of expenses for Medicare patients in the last year of life are spent in the last month, with aggressive treatments in the final month accounting for 80% of those costs.
End-of-life care spending was among factors that led the New Jersey Hospital Association to look into a statewide version for the bundle.
The 2008 Dartmouth Atlas of Health Care report found New Jersey spent the most of any state on end-of-life care for Medicare beneficiaries at $59,379, compared with the national average of $46,412 per chronically ill beneficiary. The study authors found that costs tended to be higher at facilities where more treatment options were available and that an effort to reduce costs by shifting care to rehabilitation centers, nursing homes, and home healthcare does not appear to be effective.
In response to these findings, a palliative care bundle of best practices is being tested in a collaborative of about 54 hospitals across New Jersey that are focusing on end-of life issues in their critical care units.
Aline Holmes, RN, MSN, senior vice president for clinical affairs at the New Jersey Hospital Association, said the association also is looking at how to trigger a palliative care consult for patients who might otherwise be treated aggressively in an ED.
Were looking at how we can encourage hospitals to form palliative care teams so that every patient has access to that, Holmes says. Were looking at whether there are certain triggers that would flag a patient for palliative care consult so the 95-year-old patient from a nursing home who has had dementia for years and is bedbound and unresponsive would trigger a consult to determine the goals of care.