Pilot of a Pathway to Improve the Care of Imminently Dying Oncology Inpatients in a Veterans Affairs Medical Center

Abstract

We report on the implementation of a previously developed clinical pathway for terminally ill patients, Palliative Care for Advanced Disease (PCAD), on a Veterans Administration (VA) acute care oncology unit, comparing processes of care and outcomes for patients on and off the pathway. The PCAD pathway is designed to identify imminently dying patients, review care goals, respect patients' wishes, assess and manage symptoms, address spirituality, and support family members. Retrospective chart reviews from 15 patients who died on PCAD, 14 patients who died on general wards during the same time, and 10 oncology unit patients who died prior to PCAD revealed that PCAD patients were more likely to have documentation of care goals and plans of comfort care (P=0.0001), fewer interventions, and more symptoms assessed (P=0.004), and more symptoms managed according to PCAD guidelines (P=0.02). Implementation of PCAD improved care of dying inpatients by increasing documentation of goals and plans of care, improving symptom assessment and management, and decreasing interventions at the end of life.

Recognising and managing key transitions in end of life care

“…Patients on such pathways are reviewed regularly, medication is prescribed in line with good practice guidelines, and the holistic needs of the patient and family are addressed. Entry onto an end of life care pathway depends on clinicians being alert to the possibility that the patient may be dying and is based on clinical judgment after careful assessment 20. …”

Pain and palliative medicine

“…A trial implementation of this system in a teaching hospital showed improvements in symptom assessment and management, higher likelihood of DNR orders, and decreased number of consultations [98]. This clinical pathway has been piloted on an oncology unit in a VA hospital with findings of more frequent care plans and symptom assessment and documentation [99].…”

Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty

“…Care pathways were proposed in the National Institute for Health and Clinical Excellence Guidance on Supportive and Palliative Care [55] as a possible means to improve end-of-life care, although needing more evaluation. In the USA, three before-and-after studies of care pathways suggested that there was a reduction in the number of therapies ordered, although outcomes were not studied [56-58]. Studies on the LCP in the UK found similar data using documentation and staff appraisals [59-61], and caregiver reports [60].…”