Results of survey of participants at Breaking Bad News Symposium, American Society of Clinical Oncology, ,2 However, breaking bad news is also a complex communication task.
Find articles by Anne M. Find articles by Neil S. Address reprint requests to: This article has been cited by other articles in PMC. Abstract Objectives Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order ESMO protocol that guides the use of opiate medications and other modalities to provide palliation.
Methods Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences. Results Over days, patients 2. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care.
Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use.
Nearly all clinicians found the ESMO protocol to be valuable. Conclusions A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients. Introduction When a patient is expected to die, patients, families, and health care providers usually reorient the focus of care toward comfort in a complex set of interactions.
This process is often difficult for the patient and family, and can be challenging for members of the health care team. One evaluation of patients dying in the hospital surveyed family members about the last few days of life: Physicians who deal with end-of-life issues infrequently may be less comfortable guiding care with an emphasis on comfort, especially if the institution does not have clear guidelines to direct such care.
The intervention presented here aimed to educate clinicians and change physician and nurse behavior by implementing elements of palliative care principles and practical palliative care plans via an institutional standard order set for end-of-life symptom management in a hospital without computerized orders.
Standardized order sets have been shown to facilitate care for other clinical problems such as acute coronary syndrome. The ESMO protocol was designed and implemented in a quaternary care medical center by the ethics committee in response to concerns that end-of-life symptoms were not being appropriately addressed due to knowledge deficits and concerns among clinicians regarding opiate use.
The protocol was developed by a group of clinical experts and the educational intervention consisted of general palliative care principles, models of palliative care, pharmacologic treatments, and ancillary interventions.
The protocol was placed on the hospital information system for institution-wide use for adult patients. The order protocol could be printed and placed on the written medical record. We assessed implementation of the ESMO protocol by surveying clinicians regarding their use of the order set to ascertain whether the protocol was beneficial and to identify the limitations and barriers to its use in order to inform interventions for improvement.
Methods We assessed the use of the ESMO protocol by evaluating the frequency of use and by conducting interviews with physicians and nurses providing care for patients after implementation of the ESMO protocol. The ESMO protocol contains hospital orders to guide care aimed at comfort and instructions on how to implement such care see order form in Appendix A.
The order protocol aims to overcome many of the barriers to implementation of comfort care including lack of knowledge, inexperience, and discomfort with end-of-life opiate administration.
A section of the order protocol guides ordering an opiate continuous infusion aimed at symptom control, including suggested dosing parameters and guidelines for documenting titration for unrelieved symptoms. Checkboxes prompt reconsideration of the goals of ongoing treatments. For example, the clinician might consider discontinuation of telemetry, vital signs, suctioning, and laboratory testing.
Last, referrals to social work, pain management, spiritual care, child life, and palliative care are options on the protocol that might be considered.For patients assigned to Arm 1, MEDI Upon evidence of progression following discontinuation of 12 months of treatment, patients may restart treatment with Arm 3, MEDI for up to 12 months with the same treatment guidelines followed during the initial month treatment period.
It is the purpose of this policy to clarify the legal issues surrounding consent to medical care and/or the refusal of care by minors in the pre-hospital EMS setting.
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Dec 20, · 2. Methods. This pilot study consisted of two phases, protocol development and piloting of the protocol for use with ventilator-dependent surgical intensive care patients.