Intervention Studies and Demonstrations

• 1. Keay, TJ; Alexander, C; McNally, K; Crusse, E; Eger, RE. Nursing Home Physician Education Intervention Improves End-of Life Outcomes. Palliative Medicine; 2003; 6(2):205-213. Annotation The terminal care delivery by 61 physicians who cared for 203 dying residents in 5 facilities was reviewed pre- and post-intervention, in order to determine if an educational intervention program for nursing home physicians would improve the quality of dying for residents. A half-day educational intervention program was conducted in each of the 4 facilities with 12 attending physicians who cared for the majority of the residents. Of the 4 facilities that completed the intervention, all had significant improvement in end-of-life care outcomes. Pain control, dyspnea control, and other uncomfortable symptom control improved in a highly significant degree. Use of WHO class 3 medications increased, and use of class 1 medications decreased. After the program, 48 of 91 patients in the intervention facilities were noted to be comfortable at the time of death, whereas no one was noted to be comfortable at the time of death before the program. The number of deaths from unknown causes also dropped. The charts, for residents with hospice services, included more documentation of attention to hygiene, bereavement support, and total patient comfort. [Pub Med]
• 3. Parzuchowski, J. Promoting Excellence: Integrating Cancer Care and Palliative Care. University of Michigan, Comprehensive Cancer Center; 2002; Report: 1-3. Annotation This project is a randomized trial, in a veteran’s hospital, designed to create a model for palliative care that integrates the best of cancer care and the best of end-of-life care. Intervention patients are enrolled into the program and receive both hospice and aggressive cancer care for symptom control; control patients receive traditional oncology care only.
• 4. Rosenfeld, K; Rasmussen, J. Palliative Care Management: A Veterans Administration Demonstration Project. Palliative Medicine.; 2003; 6(5):831-839. Annotation As part of a commitment to improve end-of-life care, the Veteran’s Health Administration (VA) implemented a demonstration project called Pathways of Caring at the VA Greater Los Angeles Healthcare System. The project targeted patients with inoperable lung cancer, advanced heart failure, and chronic lung disease. Utilizing an active case-finding technique, the project sought early identification and program enrollment of patients with a poor prognosis or at risk of unmet palliative care needs. Enrolled patients received interdisciplinary palliative assessment and intensive nurse care coordination to optimize symptom management, continuity, and coordination of services - across providers, care settings and support of family. To evaluate the program, the researchers used patient and family surveys as well as reviews of medical records and administrative databases. Results showed that patients enrolled in Pathways of Caring had a higher rate of advanced care planning, hospice enrollment, and death at home. Results also showed a declining rate of dying in the hospital among Pathways of Caring patients. [Pub Med]  
• 5. Tuch,H; Parrish,P; Romer,AL. Integrating Palliative Care into Nursing Homes. Palliative Medicine; 2003; 6(2):297-309. Annotation Two of the principal researchers were interviewed about a three-year intervention study, which was a collaboration of industry (Howard Tuch) and academic (Neville Strumpf) partners. The goal of the intervention was to create a model of palliative care in long-term care settings using six matched nursing homes: three in the Baltimore area and three in more rural areas, with a control nursing home for each group. The focus was on advanced care planning; pain and symptom management, and attention to spiritual and psychosocial issues for patients and families. One of two levels of involvement were implemented, either education alone or education plus the creation of a palliative care team. The results showed that both pain management and care planning spread to all residents. In addition, stability in the nursing home’s top leadership positions (including a key champion) was essential. The palliative care team model was most successful, but it also required more time, staff, and effort. Nursing home administrators reported that the presence of a palliative care program was a source of new resident referrals and having an expert in palliative care on site as part of the team was needed. The partners concluded that palliative care can be integrated into the nursing home if there is committed leadership. More information on this study including abstracts and a power point presentation can be viewed at Dr. Strumpf’s web site. [Pub Med]