A Comfort Measures Only Checklist for Critical Care Providers: Impact on Satisfaction and Symptom Management.

PURPOSE: This quality improvement project created a guide for critical care providers transitioning patients to comfort measures only encouraging communication, collaboration, and shared decision making; ensuring management of patients' end-of-life symptoms and needs; and enhancing provider satisfaction by improving structure and consistency when transitioning patients. DESCRIPTION OF THE PROJECT: Interviews conducted with staff in intensive care units revealed opportunities to improve structure and processes of transitioning patients at the end of life. A subcommittee of experts designed a checklist to facilitate interdisciplinary conversations. Impact on provider satisfaction and symptom management was assessed. Presurveys circulated used a Research Electronic Data Capture tool. A checklist was implemented for 3 months, and then postsurveys were sent. Charts were audited to identify improvement in symptom management and compared with retrospective samples. OUTCOMES: Clinical improvements were seen in communication (12%), collaboration (25%), shared decision making (22%), and order entry time (17%). In addition, 72% agreed the checklist improved structure and consistency; 69% reported improved communication, collaboration, and shared decision making; 61% felt it improved knowledge/understanding of patient needs; and 69% agreed it improved management of patient symptoms. CONCLUSION: After checklist implementation, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; no improvement in patient outcomes was realized.

Effects of an intervention to improve communication about end-of-life care among African Americans with chronic kidney disease.

The prevalence of and mortality from chronic kidney disease (CKD) are high among African Americans. Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers. Nineteen African Americans with stage 5 CKD and their surrogates were randomized to either patient-centered advance care planning (PC-ACP) or usual care. PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences (p < .05) and higher perceived quality of communication (p < .05) than do control dyads, but the two groups did not differ on other primary outcomes or acceptability measures, such as perceptions of cultural appropriateness. At posttest, 80% of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival, whereas 28.6% of patients in the control group reported that they would make that choice. At posttest, 90% of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation even if the chance of surviving the attempt would be low, whereas 57% of patients in the control group reported that they would make that choice. PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences. However, the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD.

Improving Knowledge, Comfort, and Confidence of Nurses Providing End-of-Life Care in the Hospital Setting Through Use of the CARES Tools.

Although most individuals prefer to die at home, approximately 60% of Americans die in the hospital setting. Nurses are inadequately prepared to provide end-of-life (EOL) care because of cure-focused education. Friends and family of dying patients report poor quality of death largely as a result of inadequate communication from health care professionals about the dying process. The purpose of this project was to improve nursing knowledge and comfort related to EOL care through use of the CARES tool and to improve the EOL experience of families of dying patients in the hospital setting through use of Final Journey. These acronym organized tools were developed based upon the common symptom management needs of the dying including Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, and Self-care. The CARES tool for nurses improved nursing knowledge and comfort related to EOL care and common symptom management needs of the dying and also enhanced nurses' confidence in communicating about the dying process with friends and family. Final Journey, the friends and family version of the CARES tool, reinforced EOL information for friends and family, helped nurses answer difficult questions, and promoted and enhanced communication between health care professionals and friends and family of the dying.