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Prior studies have revealed deficiencies in the care provided
to patients dying from advanced medical illnesses in acute care hospitals.
These deficiencies are best addressed through system change, which may include
the development of clinical pathways and quality improvement models. The Palliative
Care for Advanced Disease (PCAD) pathway was developed by an interdisciplinary
team and includes a carepath, a daily flowsheet, and a physician order sheet
with standard orders for symptom control. To evaluate the utility of PCAD,
the clinical pathway was introduced on three hospital units (Oncology, Geriatrics,
and an inpatient palliative care/hospice unit) as part of a quality improvement
initiative and outcomes were compared to two general medical units receiving
usual care. A chart audit tool (CAT) was used to review medical records of
101 patients who died on one of these five units during the year prior to
implementation (baseline) and 156 who died during the nine months of the PCAD
intervention. Four indices from CAT evaluated change over time: the mean number
of 1) symptoms assessed, 2) problematic symptoms, 3) interventions consistent
with PCAD, and 4) consultations requested. Nine of 27 (33%) patients on the
Oncology/Geriatrics units and all 50 patients who died on the palliative care/hospice
unit were placed on PCAD. During the PCAD intervention, dying patients who
resided on Geriatrics, Oncology and palliative care/hospice units were more
likely to have DNR orders than the comparison units, whereas the comparison
units were more likely to use "morphine infusions" and cardiopulmonary
resuscitation than the units that received the PCAD intervention. The mean
number of symptoms assessed increased significantly in all units (P < 0.001
for all comparisons). The number of problematic symptoms identified (P=0.014)
and the number of interventions consistent with PCAD increased only on the
palliative care/hospice unit (P=0.021). The number of medical consultations
declined on all units and reached significance on the Geriatrics and Oncology
units (P=0.037). Although these results reflect less than one year of the
PCAD intervention and must be considered preliminary, they suggest that 1)
a clinical pathway such as PCAD can serve as a managerial and educational
tool to improve the care of the imminently dying inpatient; 2) a PCAD clinical
pathway can be implemented on hospital units as a quality improvement initiative-a
"PCAD intervention;" 3) a PCAD intervention can change outcomes
in a positive direction, as measured using a chart audit tool; 4) a PCAD intervention
can promote aggressive symptom assessment and treatment when goals of care
are aimed at comfort; and 5) changes may occur in units that do not directly
receive the intervention, a phenomenon that suggests the possibility of diffusion.
Further study of this systems-oriented approach to change is warranted and
should include direct assessment of patient and family outcomes, as well as
measures of process. Bookbinder M, Blank AE, Arney E, Wollner D, Lesage P,
McHugh M, Indelicato RA, Harding S, Barenboim A, Mirozyev T, Portenoy RK.
Reprinted with permission from J Pain Symptom Manage. 2005 Jun;29(6):529-543.
PMID: 15963861
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15963861&query_hl=8
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