End of Life Care

Strategies to improve Palliative Care adoption and end of life care.

At our Institute, one of the biggest changes we’ve made in the past three years has been strengthening our palliative care team to support our patients.   While the team has been adopted nicely into the larger Institute, issues remain regarding timely referrals and even referrals at all from resistant services.  Too often an inpatient is referred to the program at the very end of life or after an extended time spent in the ICU.  Further downstream, hospice usage and Length of Stay also suffer due to this delayed response.  In addition, the capture of Advanced Directives and DNR orders are lacking as well.

Common responses and push back to the utilization of Palliative care is believing that the home service is actually providing the service, or doesn’t want to give up on the patient.

The team is working on a trigger to increase referrals, with MD’s being prompted with the question, “Would you be surprised if the patient were to die within a year?”.  In the event that they say “No”, the MD would be forced to state “yes” or “no” as to whether or not the patient is being referred.

I’m curious with the experience on this board.  What are the successes that you’ve had in integrating Palliative Care in your systems?  Do you have any other way to trigger referrals?  Any great successes in improving end of life care (Advanced Directives, Hospice Utilization, etc)?


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Implementing Centralized Health-System Medication Quality and Safety

Participant comments on End of Life Care

  1. Hi Rob,
    Though most Americans (71 percent in a recent survey (Harvard School of Public Health, 1999) say that their home is their preferred place of death, only 25 percent of U.S. deaths occur at home (IOM, 1997). Most of the 2.5 million deaths each year in the United States occur in institutional settings (45 percent in hospitals and 22 percent in nursing homes), and over 25 percent of Medicare expenditures go to beneficiaries’ final year of life (Riley and Lubitz, 2010). Although the above data is a bit old but the issue is similar since the evidence above support this still as an existing challenge for the health care organizations and health care teams.

    I recently came across the excellent publication and this article, “England’s Approach to Improving End-of-Life Care: A Strategy for Honoring Patients’ Choices.” This article shared the objectives of England’s end of life care strategy as below:

    Objectives of England’s End of Life Care Strategy
    •Increasing public awareness of death and dying to facilitate people’s discussion of their preferences and help drive improvements in service quality.
    •Ensuring that people are treated with dignity and respect at the end of their lives.
    •Ensuring that pain and suffering are kept to an absolute minimum by providing access to skillful symptom management.
    •Ensuring access to physical, psychological, social, and spiritual care.
    •Ensuring that people’s individual needs, priorities, and preferences for end of life care are identified, documented, reviewed, respected, and acted upon.
    •Ensuring coordination of services so that patients receive seamless care.
    •Ensuring that high-quality care is provided in the last days of life and after death in all care settings.
    •Ensuring that caregivers are appropriately supported.
    •Ensuring that health and social care professionals receive the education and training necessary for providing high-quality care.
    •Ensuring that services provide good value for the money to the taxpayer.
    Source: Department of Health, End of Life Care Strategy: Promoting High-Quality Care for All Adults at the End of Life (London: Department of Health, 2008).

    Although my posting will not give you a direct answer to your concern but definitely give you direction on how to approach this issue. In my reference list, the very first link will take you to the strategy used by England to help with almost similar concerns.


    Bradford, G, “England’s Approach to Improving End-of-Life Care: A Strategy for Honoring Patients’ Choices” 2010. Retrieved from http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1527_Gray_Englands_approach_endoflife_care_intl_brief_v2.pdf

    Harvard School of Public Health/Robert Wood Johnson Foundation poll, April 22–May 15, 1999.

    IOM, Approaching Death, 1997, 2.

    G. F. Riley and J. D. Lubitz, “Long-Term Trends in Medicare Payments in the Last Year of Life,” Health Services Research, 2010, 45(2):565–76.

  2. Rob,

    I also want to share although may not be relevant to your question directly but some of the processes related to Medicare and Medicaid related to Hospice (End of Life) are unethically misused for the financial gains. The true example is not too far from our own hometown. In NORTH TEXAS – A federal grand jury had indicted 16 Texans for their part in a health care fraud scheme. The indictment alleges that over a four-year period, the company Novus Health Services billed Medicare and Medicaid $60 million for fraudulent hospice services, of which some $35 million was paid to the company. It is very painful to read the extent of the unethical issues. The link below regarding this issue can be accessed via the link below: https://www.justice.gov/usao-ndtx/pr/sixteen-individuals-charged-60-million-medicare-fraud-scheme.

  3. Rob-we have seen and have similar issues that we have worked through and continue to work through. I am an Oncologist, so have many palliative care discussions, referrals, and now with palliative care providers embedded within our service line as a “matrix” of care. Our palliative care program started as inpatient services only, and has grown to outpatient services, including outreach clinic sites. This has been a work in progress, and the change happens slow, but does happen. We have found that involving the community has been helpful, as the population ages, the “boomers” are interested in these discussions, and often are the drivers for additional information.

    Some of the things we have done to improve referrals and awareness include:
    -embedding a palliative care provider within the physical space of departments with high referrals and usage (the opposite of “out of sight, out of mind”, is when I see and interact with our palliative care colleague every day, I send more patients, and am able to talk with patients about these members of THEIR team)
    -we initially embedded outpatient palliative care providers several half days a week, and grew within 6-12 months to need full time coverage
    -we met as physicians within Oncology to determine what patients would be appropriate for automatic referrals…metastatic solid tumors such as lung cancer, colon cancer, breast cancer, etc. Locally advanced cancers with poor prognosis such as pancreatic cancer, etc.
    -we empowered our Nurse Practitioners and Nurse Navigators and support staff with education regarding palliative care services, and benefit for patients
    -we include our palliative care physicians in our Oncology Service Line physician journal club on a monthly basis, and ask that they bring a pertinent ariticle from that month regarding palliative care
    -we include and invite palliative care providers to every tumor board conference/meeting on a weekly basis
    -we have a palliative care representative on cancer committee for the organization
    -our inpatient palliative care intersects/does a warm hand-off for transitions from inpatient to outpatient palliative care follow up
    -our palliative care providers have engaged the community with educational talks and open forums/discussion on the benefit of palliative care
    -our CEO writes a column for the local newspaper every week. Palliative Care benefits was a recent topic, with many patients bringing in the article to their physicians, wanting to discuss in regards to their health
    -our inpatient palliative care team rounds with the ICU and hospitalist teams on a daily basis
    -patients may also self-refer to palliative care
    -we did find that some of the greatest barriers are physicians who feel that perhaps they are doing the job of palliative care already, and therefore do not see the benefit of referral
    -our palliative care department tracks metrics, and brings those forward on a quarterly basis
    -our palliative care providers have done inservices with departmental and hospital staff, including education on DNR/POLST forms/difficult conversations/listening well initiatives, etc.
    -over time, this has become more “habit” as the service grows, and physicians and staff understand the benefit to patients and families. Understanding that “it takes a village”, and that myself as a physician am not always the most skilled person for every need a patient may have.
    -When I see a new patient with advanced cancer, we assess “distress” at that and each visit. We have a guide of distress 4/10 or greater warrants further discussion and referral to MSW or palliative care
    -I/we often have our palliative care providers in the exam rooms and present during the physician visit. The patients and families come to expect this, and consider those providers as part of their team. A patient asked me this week, when I introduced the palliative care RN during the visit what palliative care meant. Of course their are many answers….I like the answer of “In some ways they function in as a interpreter and advocate of your needs, goals, values, wishes, side effects, decisions etc., for you and your family with your treatment team. Sometimes physicians and patients and families think they are on the same track and goal, but come to find out perhaps more discussion is needed….”

  4. In African tradition, talking openly about death and dying is not acceptable because it is considered disrespectful, bad luck, or causes loss of hope. The dying family members is protected from knowing their prognosis. Although the hospice and palliative care movements have been instrumental in increasing awareness in end-of-life issues, many people are still not familiar with these services. For some cultures, hospice and palliative cares focus on comfort, harmony, family and support fits nicely with the culture’s values and beliefs. For cultures where dying at home is a valued norm, those values are congruent with hospice care and any palliative program.

    In our hospital set ups we are still struggling with making the palliative care programs more cultural orientated by involving the family members in decision making. We organize meeting between the families, palliative care providers and physicians. The palliative care team works in conjunction with the primary care physician and can offer assistance with end-of-life care. This includes the treatment of pain and other symptoms, emotional and spiritual support, assistance with communication of bad news, support for patients and families in medical decision-making. Despite all these efforts over 90% of the families want to take care of their dying families members at home as opposed to palliative care providers like hospice. We need more discussions and strategies to avert this trend.

  5. I don’t think this problem is unique to your setting. statistics typically show that folks in our system are not in hospice on average more than a couple of weeks before they die. We as physicians are taught how to keep people alive, and really need to shift to also helping people die with dignity. In our system we have a palliative care team in the hospital and that is good, but we still struggle outpatient wise in getting folks referred in a timely fashion. I think one key is a strong physician advocate/leader to go around and give some talks on the benefits of palliative care and hospice. Education on a regular basis is starting to move the bar a little for us.

  6. We have set up triggers in our ICU’s for a palliatative care consult to be called. It has been extremely effective for earlier involvement with the palliative care team and it removes the individual physician beliefs. We are trying to expand these triggers to patients in the inpatient units as well. Some hospitals allow the nursing team to ask for the palliative care consult as well. We have also received Joint Commission Certification for our palliative care program, and this has helped put additional structure in place

  7. Hello
    The local health integrated network has developed a system that supports palliative patients to die at home by choice and spend 15,000 fewer days in hospital by increasing the number of patients discharged home with support by 17% by 2019. We recently signed a MOU with 5 other health care agencies to support care in the community. The hospital usually has a shortage of palliative care beds as the demand is greater than our capacity. The Hospital Palliative Care Coordinator visits patients in their homes to assess their need for admission to hospital. The Palliative Care Physicians also support the community on-call roster.

  8. Since we are brought in to deliver non-clinical care to patients (oncology, gerontology, primary care, transplant, ob/gyn) we see patients turning to us for information on these things far too often, and generally in a state of confusion. There have been a number of cases when patients have been discharged without this information and have no place to turn. Although we are a safety net, what we really see a need for is helping make this a part of the conversation before it becomes too late or too obvious because it also then means the family is educated and able to make a decision vs. feeling trapped in an isolating/scary situation. In terms of integrating these services further into a practice, I think utilizing existing resources and supports outside of MD referrals, navigators, social workers, nurses who may see these concerns pop-up before a medical intervention is needed is also important in smoothing these transitions of care.

  9. Good topic. I am not very deep in this issue but I know that my organisation, a university hospital, is building and coordinating a network of palliative teams in the region (1,6 milj people). We are also building “end of life-web page” with therapeutic elements as well as advice in practical things that a dying person may find useful. There are surprisingly many aspects in a good end of life.

  10. A similar topic was just on a CNO Listserve that I am on. One of the options proposed was to add screening questions for either the MD or the RN to answer, with an automatic referral triggered if certain criteria are met. To ensure that it is completed, it could be a hard stop in the EHR (admission screening/in-patient) or be required to be completed every X months (ambulatory) in certain populations. Another potential option is to allow the nurse to “order” the consult.

    We also touched on this topic at our Medical Executive Council this morning. The physicians were very opposed to a nurse “ordering” this type of consult, even on the in-patient setting. They were slightly more open to screening questions.

  11. 2 different institutions Ive worked in faced a similar problem in the ICU. In both cases the key was to utilize social work to make the initial contact with who could benefit from a palliative care consult until the referring physicians evolved the system culture of it being more of a norm. In one institution the social worker presence in the ER was increased and any patient that met certain criteria like age or X number co-morbid conditions was screened automatically by social work and referrals for the palliative team to reach out during the hospital stay. In the second institution, during the daily ICU huddle the social worker would address the need for a consult with the ICU physician if they deemed prudent. Over time the early utilization of palliative care grew into a normalcy.

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