Supportive care pathway comforts the terminally ill
Path streamlines utilization, de-emphasizes LOS
Too often in modern health care, the last days of terminal patients are filled with the sound of alarms ringing through an intensive care unit, a confusion of laboratory tests, and painful, aggressive treatments that do little more than briefly delay the inevitable.
At Brookwood Medical Center in Birmingham, AL, Mary Ellen Caughran, MSN, RN, oncology outcomes manager, decided to change that scenario by developing a clinical pathway for the hospital's supportive care unit that stresses comfort care while reducing the number of unnecessary treatments often applied to terminal patients.
She started by collecting data from the hospital's intensive care units and examining outcomes for all terminal patients. "I knew up front that most of my data would be fairly subjective," she says. For example, one category classified some treatments as measures." "That required a judgement call by the case managers in each area. But most experienced health care providers know when they're treating and treating and there's just no benefit for the patient."
Having identified patients considered to have received such extraordinary measures, Caughran performed chart reviews for each. She also examined lengths of stay and cost data for that population of patients. "[This group of patients was] fairly high-cost, with fairly high lengths of stay for an outcome that we really expected," she says. "And it wasn't the nicest environment for the patient or the family, because ICUs usually have a lot of technology, a lot of alarms, a lot of stuff going on. They've also usually got restricted visiting hours, and that's not what most families and most patients want at the end of their life."
Caughran and Brookwood's chief nurse presented the data they had collected to the hospital's chief operating officer, who was supportive of the plan to develop a pathway to streamline the care of these patients. "Her one comment was, `I really like it when we can do the right thing for patients,'" Caughran says.
Brookwood then formed a pathway team to develop an approach by which the hospital could construct an environment that would allow terminal patients to have comfort care but no more aggressive acute care. Along the way, the team discussed how to define desirable outcomes, and what the criteria would be for determining those outcomes. They also built protocols for such activities as weaning patients from a ventilator. "We also had a protocol where, if you didn't want to just stop food or fluid, you could provide it at a low level, which would decrease the amount of secretions," Caughran says. "We also had a protocol for pain management."
The pathway differs from traditional clinical paths in a number of ways, Caughran says. These include:
· lack of tests and interventions;
· focus on both the patient and the family;
· utilization of phases of the dying process rather than days or hours;
· focus on the psychosocial, spiritual, and emotional aspects of care for the patient and family.
The pathway is restricted to patients who aren't able to return home or receive hospice care, or who are not appropriate candidates for a skilled nursing facility, Caughran says.
Also, because it's not possible to define the pathway in terms of days, the path is divided into three stages of care: admission, transition, and terminal. (See sample pathway, p. 71.)
Symptoms assessed thoroughly
The first phase involves an assessment of the patient's symptoms, whether physical, mental, emotional, or social. It's at this phase that patients are evaluated regarding the decision to withhold or stop aggressive treatment. Because of that, "We want to do an excellent assessment of symptoms that may not have been addressed completely at that point," Caughran says.
During the admission phase, patients and their families also receive a supportive care teaching packet, administered by a case manager, that outlines what patients need to know about the dying process. "Some of it is just fairly practical, like getting phone numbers together for people you need to call, making funeral arrangements, and knowing where copies of the will are," Caughran says.
The case manager also talks to the family about the process of grief, and what's likely to happen with the patient in the days ahead. "Sometimes families need to know what's going to happen and not to panic or become upset if certain physical signs occur,"Caughran says. "It helps them understand the process." In addition, a consult is scheduled for each patient with the hospital chaplain.
The transition phase, which usually begins on day two, makes up the bulk of the pathway and stresses the management of symptoms. Patient education and support for patients and families also continues.
In the final, terminal phase of the pathway, the goal is the peaceful death of the patient through continued management of symptoms and support. This phase usually commences when the patient is within a few hours of death. "At this point, you may not need to manage symptoms so much, but you really need to increase your support of family and loved ones," Caughran says.
Caughran believes that for patients at the end of life, nursing care becomes more valuable than medical care, which is geared toward acute treatment. "The focus of care needs to shift from the acute treatment of an illness to providing comfort for the dying patient with minimal technology involved," she says.
For more information, contact Mary Ellen Caughran, MSN, RN, oncology outcomes manager, Brookwood Medical Center, 2010 Brookwood Medical Center Drive, Birmingham, AL 35209. Telephone: (205) 877-1000.
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