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Service Delivery Innovation Profile

Comprehensive Palliative Care Program Improves End-of-Life Care and Pain Control for Terminally Ill Patients


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Snapshot

Summary

Hoag Memorial Hospital Presbyterian established a comprehensive, patient- and family-centered end-of-life program that includes the following components: pain control and emotional support for patients unlikely to survive the next few days; a multidisciplinary palliative care team that assists physicians who are treating patients likely to die in the next 6 to 12 months; compassionate care for parents who lose children before or after birth; and support for hospital staff who work with dying patients. Although a formal evaluation of the program has not been conducted, key elements have been widely accepted, leading to better pain control for terminally ill patients in their final days.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on pain control and use of key elements of the program, along with anecdotal reports from program officials, patients, and families.
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Developing Organizations

Hoag Memorial Hospital Presbyterian
Newport Beach, CAend do

Use By Other Organizations

Catholic Healthcare West in San Francisco is implementing similar palliative care programs in more than a dozen of its hospitals. A number of other hospitals around the country have made inquiries about Hoag's program.

Date First Implemented

1999
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Patient Population

Vulnerable Populations > Terminally illend pp

Problem Addressed

Hospitals often have difficulty providing consistent and high quality end-of-life care that best serves terminally ill patients' needs. Barriers to effective end-of-life care include the following:
  • Information/communication gaps: Patients and their family members often do not understand the potential benefits and drawbacks of medical treatments and have inaccurate perceptions of the likelihood of recovery from late-stage illness. In addition, dying patients often have not specified what measures they do and do not want taken to extend their lives when they are near death, or whether they would prefer to be at home or in a hospice. As a result, hospitals often provide treatments that briefly prolong life but cause severe pain and suffering. Often these treatments are extremely costly.1
  • Conflicting physician priorities: Busy physicians often do not have time for lengthy discussions about critical end-of-life issues with patients and their families.1
  • Insufficient palliative care and pain management: Treatment often focuses on disease management, rather than care that can reduce patient pain and discomfort.1
  • Communication problems: Physicians and hospital staff members may not know how to respond sensitively to patients' questions about their prognosis and to grieving family members.1
  • Staff grief: The loss of a patient can be very difficult for staff who have cared for the patient, and this connection and sense of loss is often ignored.

What They Did

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Description of the Innovative Activity

Hoag's comprehensive, patient- and family-centered palliative care program focuses on ensuring that care includes pain control, comfort, and emotional support; provides a multidisciplinary team to assist in developing appropriate care plans for dying patients; offers support for families who have lost a newborn; and provides support for employees who care for patients who have died. The overall goal is to better address the needs of the patient, family, and care team. Key program components include:
  • Comfort care pathway for dying patients: Patients who are identified as "actively dying" are given the option of being placed on the comfort care pathway, which consists of a standardized order set and nursing care plan designed to maximize comfort during the last days of life. Patients can also be placed on the comfort care pathway in the emergency department.
    • Symptom management: The comfort care pathway switches the focus from tests and procedures to ensuring that patients receive adequate medication to control pain, nausea, and anxiety. Pain is monitored daily via a software program that extracts pain scores from the electronic medical record.
    • Psychosocial support: Patients and families are provided with additional spiritual and emotional support, including visits from the hospital chaplain if desired. Social workers are available to discuss end-of-life treatment preferences (with participation from loved ones), taking into account religious and cultural practices.
    • Patient preferences: The comfort care pathway takes patient preferences into account; for example, families can bring a patient's favorite foods from home to the hospital. Pet visitation is also available.
  • Palliative care team: A multidisciplinary palliative care team includes a palliative care physician, advance practice nurse, social worker and chaplain, who meet daily. Usually, patients will be seen by multiple team members and sometimes in joint visits. The team helps attending physicians develop a care plan for patients with chronic illnesses who are likely to die in the next 6 to 12 months. The care team is often involved when there is a conflict between the recommendation of the primary physician and the preference of the family, or when the family and the patient are having trouble agreeing on the treatment plan.
  • Team services: When a palliative care consult is requested, the social worker initially responds, working with the family and the treatment team to facilitate decision making. When needed, the social worker can call in one of the volunteer palliative care physicians or other team members to work with the attending physician and family in developing the palliative medicine aspect of the treatment plan. Each patient receives a thorough evaluation including a physical, psychological, cultural, and spiritual assessment. Patients with a high symptom burden receive evidence-based recommendations from a board-certified palliative care specialist as well as symptom crisis management. Frequently, patients referred to the service experience spiritual distress and benefit from evaluation by the palliative care chaplain. Regular interdisciplinary meetings with a nurse, chaplain, and physician ensure that patients receive a custom-tailored, comprehensive approach to care.
  • Perinatal loss program: The Infant and Pregnancy Loss program, adapted from a similar program at Gunderson Lutheran Medical Foundation in La Crosse, WI, supports parents who lose a baby during pregnancy or soon after the birth, as described below:
    • Social worker support: A bilingual social worker assigned to the mother–baby unit becomes involved in all cases of perinatal loss.
    • Coaching for imaging professionals: Imaging professionals and other hospital personnel are coached to talk sensitively with parents when ultrasound or other evaluations reveal that the baby is in distress or has died.
    • Preservation of memories: In the hours after delivery of a stillborn baby, parents have an opportunity to hold and photograph their child and create a memory box of objects memorializing the child (e.g., a lock of hair, a birth certificate, a placard with handprints and footprints).
    • Staff alerts: To alert hospital staff that a perinatal loss has occurred, the entrance to the rooms of grieving mothers is marked with a graphic of green leaves. This sign prevents inadvertent insensitivity, such as a nurse arriving to provide training on breastfeeding.
    • Bereavement support group: A social worker and a registered nurse run a bereavement support group for parents wishing to participate.
  • Employee support: After the loss of a patient, the charge nurse can request "Tea Time for the Soul," a program led by the hospital chaplain that addresses the potential for "compassion fatigue" among hospital staff. (The program was adapted from a similar program at City of Hope Hospital in Duarte, CA.) The chaplain brings tea, treats, and music to the staff break room, where staff have the opportunity to share their experiences, express their sense of loss, or say a prayer. The chaplain will then send a letter to the patient's family on behalf of the staff.
  • Provider education and training: The palliative care team has incorporated palliative care training into hospital training requirements. All new nurses receive training from the palliative care coordinator, including instruction on how to best interact with patients and families of seriously and terminally ill patients. Palliative care case conferences are held on a monthly basis as a learning opportunity for physicians. Allied health professionals (e.g., imaging technicians and respiratory therapists) also attend training sessions that use role playing to teach them how to handle difficult questions (patients often ask allied professionals difficult questions, in part because they find these individuals less intimidating than doctors). Allied health professionals are also encouraged to read the book Tuesdays with Morrie by Mitch Albom.
  • Education for patients and family members: The program offers information in brochures and on the hospital Web site that helps family members cope with end-of-life issues and bereavement. In plain language, the information covers what happens to terminally ill people and how loved ones should respond, and what to do after a patient's death. The brochures also include resources, contacts, checklists, and information about stages of grief, along with suggestions on handling depression and talking with children.
  • Monitoring and tracking: Program staff track data relevant to patient quality of life and costs of care, including satisfaction with pain control, physician use of the supportive care pathway, and patient length of stay. Program staff meet weekly to review patients currently receiving palliative care and discuss patients who might benefit from the program.
  • Community outreach: Although the program is hospital based, its success has led to regular inquiries from outside the hospital. The program coordinator fields requests for end-of-life information from patients and families, outpatient program personnel, churches, and other community organizations.
  • Program development: At the hospital level, a program development team meets monthly and includes the vision of nursing leaders, pharmacists, and key physicians.

Context of the Innovation

Hoag Memorial Hospital Presbyterian is a 498-bed acute care, nonprofit community hospital in Newport Beach, CA. Hoag offers a comprehensive mix of health care services, including centers for cancer care, cardiac and vascular problems, orthopedics, and women's health services. The end-of-life program was developed in late 1999, when the hospital ethics committee decided to evaluate the quality of the end-of-life care being provided at the hospital. After staff surveys and family interviews identified opportunities for improvement, the committee developed a process improvement plan that began with the comfort care pathway and later expanded into the comprehensive palliative care program. At the same time, the issue of palliative care began receiving increased attention in California in the wake of a case of neglect at a hospital, with the state passing legislation requiring 12 continuing education credits in end-of-life issues and pain management for all licensed physicians except for radiologists and pathologists.

Did It Work?

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Results

Although an indepth evaluation of the program's impact has not been conducted, key elements of the program have been widely adopted, resulting in adequate pain control for the vast majority of dying patients. Program officials, moreover, are confident that it has significantly improved patients' quality of life.
  • Broad use of program elements: The comfort care pathway is used in more than 50 percent of hospital deaths. In the critical care units, 70 percent of deaths occur on comfort care.
  • Adequate pain control: Ninety-nine percent of patients on the pathway report achieving adequate pain control within 24 hours, according to pain scores extracted from the electronic medical record.
  • Anecdotal reports of program success: Program officials, patients, and families have reported that the program has allowed physical and emotional comfort at the end of life. The hospital is planning to implement a patient/family satisfaction survey of palliative care program.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on pain control and use of key elements of the program, along with anecdotal reports from program officials, patients, and families.

How They Did It

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Planning and Development Process

Planning and development included the following elements:
  • Team formation and data gathering: In 1999, recognizing the need to improve the consistency of end-of-life care, hospital officials formed a team to examine the experiences of dying patients and their families and identify improvement opportunities. The team, directed by the ethics committee chairperson, surveyed hospital staff (including doctors, nurses, social workers, and other allied health professionals) and interviewed families who had lost a loved one in the previous 3 to 6 months. The team concluded that establishing a permanent program focused on palliative care would be the best way to improve end-of-life care.
  • Hiring a coordinator: In 2000, a social worker was hired to coordinate the hospital's end-of-life program.
  • Development of pathway and training materials: The program coordinator worked with several physicians and nurses to establish the comfort care pathway, develop teaching materials on end-of-life issues for family members, and train nursing and medical staff in providing high quality end-of-life care.
  • Program expansion: In 2003, with the comfort care pathway on firm footing, program officials asked additional hospital staff if they wanted to become more involved in palliative care. The response was strong, leading to the formation of the palliative care consulting team and the perinatal loss program.

Resources Used and Skills Needed

  • Staffing: The program began by being staffed with one full-time employee, a social worker; all other hospital staff participated as part of their regular jobs. In 2008, a palliative care advanced practice nurse became the coordinator; a board-certified palliative care physician was added in March 2009, and a social worker was also added part-time, going to full-time in September. The chaplain continues to be part of the team on an as-needed basis.
  • Costs: Program costs include the salary for the one full-time equivalent social worker as well as patient and family education materials.
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Funding Sources

The program is funded by the hospital's internal operating budget (which funds the social worker's salary) and supplemented by donor grants (which cover the costs of patient and family education materials).end fs

Tools and Other Resources

Information the hospital prepared for family members coping with end-of-life issues is available on the Hoag Web site at: http://www.hoag.org/Services/End-of-Life-Care/Pages/Home.aspx.

Adoption Considerations

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Getting Started with This Innovation

  • Make the case for palliative care: Some hospital administrators may be skeptical that palliative care should be a priority. The following strategies may be helpful in building support:
    • Personalize the issue: Emphasize that almost everyone has faced or will face important end-of-life decisions in caring for their parents or other close relatives. Once people can relate to the issue, they are more likely to support the program.
    • Promote cradle-to-grave care: Show how palliative care fits into the hospital's overall mission by documenting the number of patients who die each year in the hospital. Often hospital administrators are unaware of this number.
    • Discuss cost issues: Emphasize that palliative care programs do not require additional beds (because patients are already being treated). Costs may drop as patients spend less time in intensive care units, receive fewer aggressive treatments in their final days, and leave the hospital for hospice care.
  • Be flexible in choosing program leaders: There is no standard template for the ideal background for a leader of a palliative care program. Successful directors have included physicians, social workers, nurses, and chaplains.
  • Sell the benefits to physicians: The program lifts a burden from physicians, who typically cannot spend extended time answering questions about end-of-life issues posed by patients and their families. Instead, social workers and nurses trained in palliative care get to know the patients and their families, gain their trust, provide effective psychosocial support, and help them make informed decisions.

Sustaining This Innovation

  • Focus on developing physician support: Some physicians resist palliative care, believing all measures to extend life should always be used. Early on, program officials should make working with physicians who support the program a priority. Once resistant physicians see the program's benefits for doctors, patients, and their family members, they may be more inclined to participate.
  • Document successes: To maintain program support, seek and share statistics that show the program reduces costs, including lower length of stay and fewer treatments during patients' final days.

Use By Other Organizations

Catholic Healthcare West in San Francisco is implementing similar palliative care programs in more than a dozen of its hospitals. A number of other hospitals around the country have made inquiries about Hoag's program.

Additional Considerations

This program does not require a major commitment of new personnel. A hospital palliative program can be successfully coordinated by one full-time employee.

More Information

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Contact the Innovator

Paul Selecky, MD
Director of Palliative Care
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92663
Phone: (949) 764-5515
E-mail: pselecky@hoaghospital.org

Innovator Disclosures

Dr. Selecky has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Award Winner: Palliative end-of-life care program: Hoag Memorial Hospital Presbyterian. American Hospital Association article. Available at: http://www.aha.org/aha/content/2005/pdf/COL_2005_Hoag.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Hoag Hospital. End-of-life care [Web site]. Available at: http://www.hoag.org/services/End-of-Life-Care/Pages/Home.aspx.

Hoag Hospital. Pregnancy and infant loss program [Web site]. Available at: http://www.hoag.org/Specialty/WomensHealth/Pages/Pregnancy-Infant-Loss.aspx.

Footnotes

1 Oasis Healthcare, Inc. Physicians urged to guide patients to more effective use of hospice care. Quality of Life Matters 2005;7(2):1-2.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 07, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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