Assessment of Implementation of an Order Protocol for End-of-Life Symptom Management

Abstract

Objectives: Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order (ESMO) protocol that guides the use of opiate medications and other modalities to provide palliation.Methods: Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences.Results: Over 342 days, 127 patients (2.6 per week) were treated using the ESMO protocol and we surveyed a nurse and/or physician for 105 (83%) patients. Most patients were comatose, obtunded/stuperous, or disoriented when the ESMO protocol was initiated and most had a life expectancy of less than 1 day. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care. Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use. Nearly all clinicians found the ESMO protocol to be valuable.Conclusions: A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients. 857

An Observational Study on a Protocol for Withdrawal of Life-Sustaining Measures on Two Non-Academic Intensive Care Units in The Netherlands: Few Signs of Distress, No Suffering?

“…26,27 This guideline was adopted as the national end-of-life protocol by the Dutch Intensive Care Society in 2008. Walling et al 28 showed in that same year that a protocol for end-of-life care symptom management is indeed feasible and useful.…”

Variable Patterns of Continuous Morphine Infusions at End of Life

“…2,3 Both the public and health care professionals often mistakenly believe opioid use will hasten death, when in fact appropriately dosed opioids can significantly improve pain and extend time until death. 4 According to the World Health Organization, properly dosed and titrated opioids are the medication of choice for pain management at the EOL. 5 A recent article shows that morphine is the most common opioid used at EOL.…”

Missed Opportunities: Use of an End-of-Life Symptom Management Order Protocol among Inpatients Dying Expected Deaths

“…Evaluation of the implementation of the ESMO protocol by interviewing physicians and nurses suggested that comfort measures were instituted late one quarter of the time and most patients had a life expectancy of less than 1 day. 3 When cure is no longer possible and patients are anticipated to be close to death, the best plan of care often focuses on comfort. Unfortunately, there are many barriers to the transition from curative to comfort care.…”

“…In the interview study that led to the current chart-based analysis, 3 physicians often reported that the ESMO protocol was instituted too late and their explanation for that nearly always was that ''the patient (or family) was not ready.'' Why weren't these patients and families ready?…”

“…A prospective study found that of 127 patients treated with the ESMO protocol, 120 died in the hospital and only 7 were discharged from the hospital. 3 Also, the analysis is crosssectional; the associations detected cannot be assumed to be causal. However, we are able to identify subgroups of patients that have low rates of ESMO protocol use that identifies potential targets for quality improvement.…”