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Abstract

Background:

There are few published comfort care order sets for end-of-life symptom management, contributing to variability in treatment of common symptoms. At our academic medical centers, we have observed that rapid titration of opioid infusions using our original comfort care order set's titration algorithm causes increased discomfort from opioid toxicity.

Objective:

The aim of this study was to describe the process and outcomes of a multiyear revision of a standardized comfort care order set for clinicians to treat end-of-life symptoms in hospitalized patients.

Design:

Our revision process included interdisciplinary group meetings, literature review and expert consultation, beta testing protocols with end users, and soliciting feedback from key committees at our institutions. We focused on opioid dosing and embedding treatment algorithms and guidelines within the order set for clinicians.

Setting:

The study was conducted at two large academic medical centers.

Results:

We developed and implemented a comfort care order set with opioid dosing that reflects current pharmacologic principles and expert recommendations. Educational tools and reference materials are embedded within the order set in the electronic medical record. There are prompts for improved collaboration between ordering clinicians, nurses, and palliative care.

Conclusions:

We successfully developed a new comfort care order set at our institutions that can serve as a resource for others. Further evaluation of this order set is needed.

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References

Smith

, Cenzer

, Knight

, et al.: The epidemiology of pain during the last 2 years of life. Ann Intern Med, 2010; 153:563–569.

Kehl

, Kowalkowski

: A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. Am J Hosp Palliat Care, 2013; 30:601–616.

Lynn

, Teno

, Phillips

, et al.: Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med, 1997; 126:97–106.

Committee on Approaching Death: Addressing Key End of Life Issues, Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press, 2015.

Downey

, Curtis

, Lafferty

, et al.: The Quality of Dying and Death (QODD) questionnaire: Empirical domains and theoretical perspectives. J Pain Symptom Manage, 2010; 39:9.

Downey

, Engelberg

, Curtis

, et al.: Shared priorities for the end-of-life period. J Pain Symptom Manage, 2009; 37:175–188.

Farber

, Egnew

, Herman-Bertsch

, et al.: Issues in end-of-life care: Patient, caregiver, and clinician perceptions. J Palliat Med, 2003; 6:19–31.

Walling

, Tisnado

, Asch

, et al.: The quality of supportive cancer care in the Veterans Affairs Health System and targets for improvement. J Gen Intern Med, 2014; 29:836–843.

Teno

, Clarridge

, Casey

, et al.: Family perspectives on end-of-life care at the last place of care. JAMA, 2004; 291:88–93.

10.

The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Treatments (SUPPORT). JAMA, 1995; 274:1591–1598.

11.

Kutner

, Bryant

, Beaty

, Fairclough

: Time course and characteristics of system distress and quality of life at the end of life. J Pain Symptom Manage, 2007; 34: 227–236.

12.

Levy

: Making a personal relationship with death. In: Curtis

, Rubenfeld

(eds): Managing Death in the Intensive Care Unit. The Transition from Cure to Comfort. New York: Oxford University Press, 2001, pp. 31–36.

13.

Weissman

, Meier

: Identifying patients in need of a palliative care assessment in the hospital setting: A consensus report from the Center to Advance Palliative Care. J Palliat Med, 2011; 14:17–23.

14.

Bailey

, Williams

, Goode

, et al.: Opioid pain medication orders and administration in the last days of life. J Pain Symptom Manage, 2012; 44:681–691.

15.

McPherson

, Kim

, Walker

: 50 practical medication tips at end of life. J Support Oncol, 2012; 10:222–229.

16.

Bookbinder

, Arceo

: Improving the quality of care across all settings. In: Oxford Textbook of Palliative Nursing. New York: Oxford University Press, 2014, pp. 683–698 & Appendix 44.1.

17.

Bailey

, Burgio

, Woodby

, et al.: Improving processes of hospital care during the last hours of life. Arch Intern Med, 2005; 165:1722–1727.

18.

Foley

: Pain and symptom control and Principles and practice of withdrawing life-sustaining treatment in the ICU. In: Curtis

, Rubenfeld

(eds): Managing Death in the Intensive Care Unit. The Transition from Cure to Comfort. New York: Oxford University Press, 2001, pp. 103–117, 127–147.

19.

Shehabi

, Bellomo

, Mehta

, et al.: Intensive care sedation: The past, present, and the future. Crit Care, 2013; 17:322.

20.

Chan

, Treece

, Engelberg

, et al.: Narcotic and benzodiazepine use after withdrawal of life support. Chest, 2004; 126:286–293.

21.

Treece

, Engelberg

, Crowley

, et al.: Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med, 2004; 32:1141–1148.

22.

Barr

, Fraser

, Puntillo

, et al.: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med, 2013; 41:263–306.

23.

Chan

, Webster

, Bowers

: End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database Syst Rev, 2016; 2:CD008006.

24.

Neuberger

: More Care, Less Pathway: A review of the Liverpool Care Pathway. 2013. www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf (Last accessed November 1, 2016).

25.

Kullgren

, Le

, Wheeler

: Incidence of hydromorphone-induced neuroexcitation in hospice patients. J Palliat Med, 2013; 16:1205–1209.

26.

Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6e. American Pain Society. Glenview, IL: American Pain Society, 2008.

27.

McPherson

: Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. American Society of Health-System Pharmacists, Bethesda, MD, 2010.

28.

Walling

, Brown-Saltzman

, Barry

, et al.: Assessment of implementation of an order protocol for end-of-life symptom management. J Palliat Med, 2008; 11:857–865.

29.

Walling

, Ettner

, Barry

, et al.: Missed opportunities: Use of an end-of-life symptom management order protocol among inpatients dying expected deaths. J Palliat Med, 2011; 14:407–412.

30.

Bookbinder

, Blank

, Arney

, et al.: Improving end-of-life care: Development and pilot-test of a clinical pathway. J Pain Symptom Manage, 2005; 29:529–543.

31.

Luhrs

, Meghani

, Homel

, et al.: Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center. J Pain Symptom Manage, 2005; 29:544–551.

32.

Bailey

, Williams

, Woodby

, et al.: Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med, 2014; 29:836–843.

33.

Glare

, Dickman

, Goodman

: Symptom control in care of the dying. In: Ellershaw

, Wilkinson

(eds): Care for the Dying: A Pathway to Excellence. New York: Oxford University Press, 2011, pp. 1–44.

34.

Phillips

, Halcomb

, Davidson

: End-of-life care pathways in acute and hospice care: An integrative review. J Pain Symptom Manage, 2011; 41:940–955.

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A New Generation of Comfort Care Order Sets: Aligning Protocols with Current Principles

Abstract

Abstract

Background:

Objective:

Design:

Setting:

Results:

Conclusions:

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References

Supplementary Material