Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

Abstract

BACKGROUND: Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE: To evaluate the effectiveness of a multimodal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN: Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS: Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION: Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES: Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n= 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, donot-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS: Significant intervention effects were observed for orders for opioid pain medication (OR:

Use of Palliative Care and Hospice Among Surgical and Medical Specialties in the Veterans Health Administration

“…That trial produced modest yet statistically significant increases in the use of advanced directives and pain management. 10 Since this trial, the VHA has developed further interventions to improve end-of-life care further, reflected in the 2008 VHA directive. Qualitative differences in the medical and surgical specialties are known regarding end-of-life and advanced care planning.…”

Continuation of non-essential medications in actively dying hospitalised patients

“…Findings previously reported elsewhere indicate that the BEACON intervention was effective in significantly increasing orders and use of opioids, antipsychotics and medication for death rattle,19 suggesting that more patients had been recognised as actively dying and that pre-emptive care plans for expected symptoms had been instituted using the guidance of a comfort care order set. In the current study, a secondary analysis of data from the BEACON trial was performed to evaluate the continued orders of 11 medications that were considered a priori to be non-essential in the imminently dying patient based on expert opinion, clinical experience and review of geriatric and palliative care literature 20–23…”

“…This study involves a planned secondary analysis of data from the ‘Best Practices for End-of-Life Care for Our Nation’s Veterans’ trial (BEACON) 19. The BEACON study was a real-world, multisite implementation trial designed to evaluate the impact of an intervention strategy to improve processes of end-of-life care in six VAMCs.…”

Therapeutic Actions Promoted To Terminal Patient: Professional Experience At Home Care Service

“…In accordance with the effectiveness of opioid, studies indicate the morphine as the first drug to be administered to the patient in the critical phase of the illness to relieve his pain. [12,[24][25] However, the World Health Organization recommends that the analgesia directed to the patients without prospect of cure must obey clinical criteria, the intensity of the symptoms and the approach of "WHO's analgesic scale". [22] Concerning the analgesic scale, this is a proposal that adapted the use of analgesics according to the intensity of the pain, that must be evaluated by following three steps: the first one is directed to the treatment of mild pain, using non-opioid analgesics and anti-inflammatories; the second one is recommended for patients with moderate pain with the use of weak opioids, combined with non-opioid analgesics and adjuvants; and the third one is reserved for patients with severe pain, in which the weak opioids are replaced by the strong ones, like morphine, methadone, oxycodone and fentanyl, associated with non-opioid analgesics and adjuvants.…”

“…[5][6][7] Within these possibilities, the Home Care Service is an important strategy that can be employed to expand care for the user and his family, and that stands as a mainstay of fundamental relevance to qualify health care and humanize the assistance to the terminally ill, especially in the reality of countries with limited resources in health and scarce institutional possibilities for caring at the end of life. [4,8] Studies show home as a potentiating space in the care given to the patient in the finitude of life and emphasize the importance of therapeutic actions designed by multidisciplinary teams to alleviate the suffering of the patient and his family [9][10][11][12], with the central focus on Palliative Care. However, at the national level, there is an incipient quantitative of studies related to the themes mentioned.…”