Methodological challenges in conducting instrumentation research in non-communicative palliative care patients.

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

Creative solution for implementation of experiential, competency-based palliative care training for internal medicine residents.

To graduate internal medicine residents with basic competency in palliative care, we employ a two-pronged strategy targeted at both residents and attending physicians as learners. The first prong provides a knowledge foundation using web-based learning programs designed specifically for residents and clinical faculty members. The second prong is assessment of resident competency in key palliative care domains by faculty members using direct observation during clinical rotations. The faculty training program contains Competency Assessment Tools addressing 19 topics distributed amongst four broad palliative care domains designed to assist faculty members in making the clinical competency assessments. Residents are required to complete their web-based training by the end of their internship year; they must demonstrate competency in one skill from each of the four broad palliative care domains prior to graduation. Resident and faculty evaluation of the training programs is favorable. Outcome-based measures are planned to evaluate long-term program effectiveness.

Length of hospice care among U.S. adults: 1992-2000.

This study examined length of service use among U.S. adult hospice patients based on data from the 1992-2000 National Home and Hospice Care Surveys. With the Kaplan-Meier method, we estimated length of service use of current and discharged hospice patients simultaneously. Using a multivariate Cox proportional hazards model, we examined trends in patients' service use during the 1990s. Findings show that length of service use decreased significantly among adult patients who had Medicare as their only payment source. Although overall length of service use declined significantly in 1996, 1998, and 2000 compared to 1992, it was similar between 1996 and 2000.

Nursing home physician educational intervention improves end-of-life outcomes.

CONTEXT: Nursing homes are the setting for one of five deaths in the United States. Unfortunately these deaths are often accompanied by pain and symptoms of discomfort. OBJECTIVE: To determine if an educational intervention designed for nursing home physicians improves the quality of dying for nursing home residents. DESIGN: Prospective measurement of changes in end-of-life medical care indicators. INTERVENTION: Half-day adult educational outreach program, including audit and feedback, targeted at opinion leaders, and quality improvement suggestions. SETTING: Five geographically diverse Maryland skilled nursing facilities with a total of 654 beds. PARTICIPANTS: The terminal care delivered by 61 physicians who cared for 203 dying residents in the 5 facilities was reviewed. An intervention was targeted to medical directors and those physicians with the majority of patients. Twelve physicians participated in the educational program. MAIN OUTCOME MEASURES: Chart documentation of recognition of possible death, presence of advance directives, pain control, analgesics used, dyspnea control, control of uncomfortable symptoms during the dying process, documented hygiene, documented bereavement support, and total patient comfort. RESULTS: The four nursing facilities that completed the intervention all had significant improvements in end-of-life care outcomes (p < 0.001, chi2). No statistically significant changes were found in any measure in the cohort nursing facility that did not complete the intervention. When we compared residents with hospice services to those without, we found significant increases in documentation of better hygiene, bereavement support, and total patient comfort (p < 0.001, chi2 for each). CONCLUSIONS: Important terminal care outcomes can be significantly improved by targeting key nursing home physicians with an adult educational program that includes audit and feedback, and quality improvement suggestions.

National trends in adult hospice use: 1991-1992 to 1999-2000.

This study examines hospice use among adult hospice patients based on the 1992-2000 National Home and Hospice Care Surveys, the 1997-1999 National Nursing Home Surveys, and the 1991-2000 annual Underlying and Multiple Cause-of-Death Files. The total number of adult hospice patients tripled between 1991-1992 and 1999-2000. The majority of inpatient hospice patients resided in nursing homes. The increased hospice utilization rates and increased percentage of adult hospice patients with short stays in hospice indicate changes in hospice enrollment patterns over time. Hospice is still in the process of growing toward a steady state.

Development of required postgraduate palliative care training for internal medicine residents and medical oncology fellows.

BACKGROUND: The need for better care for terminally ill patients led us to create an educational program to provide internal medicine residents and medical oncology fellows basic competency in palliative and end-of-life care. METHODS: An interdisciplinary team identified educational strategies, course objectives, content, and evaluation instruments. RESULTS AND CONCLUSIONS: Our strategy is to use a required Web-based course to establish a knowledge base upon which specific training during clinical rotations build skills. Field testing of the Web course showed it was an effective tool for delivering clinically applicable content. Skill building experiences are now being integrated into selected clinical rotations.