The Role of Spiritual Care with the Introduction of an End of Life Order Set.

Delivering comprehensive end-of-life care to dying patients must involve addressing physical symptoms and psychosocial concerns. Care pathways have been introduced to support health care teams in delivering this care. This retrospective chart review explores the contributions of the Spiritual Care Team in the care of dying patients. They offer a range of interventions which include supportive care, religious and spiritual support. This study was one step towards appreciating the contributions of the Spiritual Care Team.

Improving end-of-life care through quality improvement.

Although end of life (EoL) care has been identified as an area for quality improvement in hospitals, the quality of care Canadian patients receive at the end of life is not well-evidenced. National statistics indicate that Canadians would prefer to die at home, yet more than 50% die in acute care hospital settings. Busy and often highly specialised acute care units may be perceived as a distressing place of death for both patients and their families. Furthermore, many clinicians are not trained in diagnosing imminent dying, managing symptoms at the end of life or supporting dying patients and their families. As such, to improve the experience of EoL care, a corporate, institution-wide strategy entitled the Quality Dying Initiative was introduced and implemented across a tertiary care academic teaching hospital. A primary focus of this initiative was the implementation of a comprehensive Comfort Measures Strategy. This strategy involved the development of an evidence-based order set, which included elements of symptom assessment and management, patient and family education, and spiritual and emotional support. Staff education and mentoring was also a critical element of the larger Comfort Measures Strategy, as well as an evaluative component.

Clinician accuracy when estimating survival duration: the role of the patient's performance status and time-based prognostic categories.

CONTEXT: Although shown to be an independent predictor of actual survival (AS) duration, previous reports have identified significant inaccuracy in clinician estimates of survival (CES). OBJECTIVES: This study aimed to both examine demographic and clinical factors potentially impacting CES accuracy and explore possible strategies for improvement in a patient population with advanced incurable disease. METHODS: At the time of initial assessment by a specialist palliative care team, CES for each patient was chosen from one of the following time-based categories: <24 hours, one to seven days, one to four weeks, one to three months, three to six months, three to 12 months, or >12 months. Survival estimates were then classified as an accurate (AS=CES), overestimate (ASCES). Demographic data were analyzed using descriptive statistics, and both univariate and stepwise multivariate logistic regression analyses were used to identify any associated demographic and/or clinical factors significantly impacting accuracy. RESULTS: Within the total study population of 1835, both CES and AS data were available for 1622 patients among whom mean and median survival was 26.5 and 88 days, respectively. The remaining 213 patients (12% of the total population) remained alive at the time of analysis. Of the total study population, CES was accurate for 34% of patients and an overestimate for 51% of patients. CES of <24 hours and one to seven days were significantly more likely to be accurate than any other prognostic category (P<0.0001). Additionally, a CES of either one to four weeks or >12 months was significantly more likely to be accurate than CES of one to three months, three to six months, and six to 12 months (P<0.0001). Finally, multivariate analyses indicated CES to be significantly more likely to be accurate for males (P=0.0407) and for patients with baseline Palliative Performance Scale (PPS) ratings of either "30 and less" (P<0.0001) or "70 and greater" (P<0.0001). CONCLUSION: In a patient population referred for specialist palliative care consultation with diverse diagnoses and a wide range of CES, time-based categorization of survival estimates along with PPS and possibly gender could be used to inform the CES process for individual patients. Intentionally incorporating these objective elements into what has historically been the subjective process of CES may lead to improvements in accuracy.

Evaluating correlation and interrater reliability for four performance scales in the palliative care setting.

Performance scales are used by clinicians to objectively represent a patient's level of function and have been shown to be important predictors of response to therapy and survival. Four different scales are commonly used in the palliative care setting, two of which were specifically developed to more accurately represent this population. It remains unclear which scale is best suited for this setting. The objectives of this study were to determine the correlations among the four scales and concurrently compare interrater reliability for each. Patients were each assessed at the same point in time by three different health care professionals, and all four scales were used to rate each patient. Spearman correlation coefficient values and both weighted and unweighted kappa values were calculated to determine correlation and interrater reliability. The results confirmed highly significant linear correlation among and between all four scales. Whether using a reliability measure that incorporates the concept of "partial credit" for "near misses" or a measure reflecting exact rater agreement, no one scale emerged as having a significantly higher likelihood of agreement among raters. We propose that what may be more important than clinical experience or rater profession is the level of training an individual health care professional rater receives on the administration of any particular performance scale. In addition, given that low levels of exact rater agreement could have substantial clinical implications for patients, we suggest that this parameter be considered in the design of future comparative studies.