Missed Opportunities

Use of an End-of-Life Symptom Management Order Protocol Among Inpatients Dying Expected Deaths

Published In: Journal of Palliative Medicine, v. 14, no. 4, Apr. 6, 2011, p. 407-412

Posted on RAND.org on March 31, 2011

by Anne Walling, Susan L. Ettner, Tod Barry, Myrtle C. Yamamoto, Neil S. Wenger

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BACKGROUND: When a patient is expected to die, the ideal plan of care focuses on comfort. Prior investigation of application of one institution's end-of-life symptom management order (ESMO) protocol suggested that comfort measures were often instituted too late and sometimes not at all. We studied patient factors associated with missed opportunities for use of an ESMO protocol and protocol adherence in order to identify areas for quality improvement. METHODS: We abstracted the terminal hospitalization medical record for all adult decedents hospitalized for at least 3 days between April 2005 and April 2006 (n = 496) at a university medical center. Detailed information was collected about ESMO use and opiate titration at the end of life. Among patients expected to die, we used multivariate logistic regression to evaluate factors associated with whether patients were placed on the ESMO protocol prior to death. RESULTS: Half of patients who died received ESMO protocol care (n = 248). All had documentation of a do-not-resuscitate (DNR) order (a requirement of the protocol). An opiate drip was used for 95% of patients placed on the ESMO protocol and it was titrated up at least once for 67% of those patients. Patients had a mean of 4 opiate titrations, but for only a mean of 2.2 was a justification documented (symptom documentation is required for each titration per the protocol). In a multivariable regression accounting for other demographic, clinical and provider variables, uninsured patients (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.06–0.62), patients admitted from a nursing home (RR 0.57, 95% CI 0.30–0.99), and patients considered for transplant (RR 0.60, 95% CI 0.40–0.85) were significantly less likely to be placed on the ESMO protocol prior to death. CONCLUSIONS: Evaluation of implementation of a standardized order set can identify areas for quality improvement and missed opportunities for use.

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