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Assessment of implementation of an order protocol for end-of-life symptom management
Anne M Walling1, Katherine Brown-Saltzman, Tod Barry
1Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA 90095, USA. awalling@mednet.ucla.edu
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.
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