Waldrop and Kirkendall (2009) surveyed employees from a 120-bed suburban nonprofit nursing home to explore how their staff recognized a dying patient and identified standards of care which would be put into place once palliative care has been initiated. Using a qualitative method to gather data, 42 employees were interviewed which included nurses, chaplains, social workers, nursing assistants, housekeepers, and administrators to provide multiple perspectives on the dying experience. The survey was done in the form of a 30-minute interview in a quiet location of the nursing home away from the nursing unit (Waldrop & Kirkensall, 2009). An affiliated research assistant or investigator whom has had training in conducting interviews and qualitative data analysis conducted it. They asked the employees open-ended and objective questions about frequency and standards of care for dying patients and their families. “All interviews were audio taped, transcribed by a professional transcriptionist, and labeled with a letter number combination (e.g., N[urse]-1). The transcripts were entered into Atlas ti software for data organization and management”(Waldrop & Kirkensall, 2009). The survey identified physical, behavioral, and social factors as the three main indicators of impending death. Physical indicators included altered breathing patterns (including apnea), anorexia, or increase in pain; behavioral indicators included mood changes and diminished activity level and social indicators sometimes included withdrawal from interaction with staff or family (Waldrop & Kirkendall, 2009). During the survey the staff explained that Comfort care is initiated when patients began to exhibit these signs. At this nursing home standard order sets were not used and comfort care measures were described as being very patient individualized and holistic. Comfort care includes an interrelationship of symptom management, family care, interpersonal relationships, and interdisciplinary cooperation in which each member of the healthcare team participates in the care of the patient, according to their scope of practice (Waldrop & Kirkendall, 2009).
The survey revealed that health care employees deliver comfort care in different ways and it identified the need for more comparison studies in other nursing homes to explore standards of care in other facilities because this was just one study of one nursing home. By further comparing nursing homes which use different models of care comfort care standards and or improvements can be made. This survey was conducted in a nursing home setting but its results reflect on hospital end-of-life care. At the present time the standard of care for dying patients in a hospital setting consists of pre-printed order sets which are not individualized to the specific needs of the patient. This study promotes use of the holistic, individualized care approach to ensure a more satisfying and comforting dying experience.
Level of evidence: VI Single descriptive qualitative/physiologic study
Jarabek, B.R., Cha, S.S., Ruegg, S.R., Moynihan, T.J., & McDonald, F.S. (2008). Use of a palliative care order set to improve resident comfort with symptom management in palliative care. Palliative Medicine, 22, 343-349.
Jarabek, Cha, Ruegg, Moynihan, & McDonald, (2008) began a study within the Internal Medicine Residency Program at Mayo Clinic in Rochester, Minnesota hypothesized that standard palliative order sets within a hospital setting would enhance physician comfort with managing 4 aspects of end-of-life care: pain, secretions, agitation, and dyspnea. A 5-question, pre-intervention web-based survey regarding physician comfort in diverse aspects of palliative care was given to 144 internal medicine resident physicians before the release of the palliative order set, which would later be used within the hospital. Each question included a 5-item Likert response scale, ranging from 1, “very comfortable” to 5, “very uncomfortable”(Larabek et al., 2008). Three months later an educational email was sent to all house staff and faculty addressing end-of life-care along with the initiation of the order set, which consisted of physical ailment provisions. Another 3 months was spent allowing staff to use and or work with the order sets at which point a post-intervention survey was performed. Results of the post-intervention survey were that 88% had utilized the palliative order sets and 63% stated that they felt increasingly comfortable with palliative care (Jarabek et al., 2008). There was an overall 10% increase in resident comfort regarding the 4 aspects of palliative care with the initiation of order sets, but no change in social or communication-related comfort (Jarabek et al., 2008). The survey concluded that palliative order sets can increase physician comfort in providing care to patients during end-of-life, but it also revealed that the order sets do not address the psychosocial needs of the patient when providing comfort care. Although physicians find comfort in having order sets as guidelines for end-of-life care, they are only guidelines and open communication needs to be initiated between the health care team and the patient to ensure all the comfort care needs of the patient and family are met in a holistic way so that they may have a peaceful dying experience.