Vol IX, Nov `04

"There are many studies about pain and symptom management at the end of life, but few address how physician practices influence EOL care," Lieto told her audience at the Network meeting. This gap in research led her to undertake this study, which had several aims. These included:

• Determining if and when physicians are discussing when a patient's care changes from disease management into symptom management in facilities
• If and when hospice is discussed and used, determining if physicians regard the spiritual aspect of dying
• Assessing if practitioners felt that their patients had a "good death." Lieto said that she hopes her study will help facilitate education and interventions to improve the dying process in nursing homes

The prospective card survey study involved AMDA Research Network members providing information on consecutive nursing home deaths over a one-month period. As of October 15, 2004, 51 respondents returned data on 233 patients for an 18% response rate. Data compiled revealed:

• 199 patients had documentation regarding palliative care discussions in their records
• The physician or nurse practitioner initiated these discussions in 66.5% of instances; in 13.7% of cases, other staff started these talks
• At the time of death, 94.4% of patients had Do Not Resuscitate orders; 56.2% had Do Not Hospitalize Orders; 76.4% had comfort care or terminal care orders
• While 85.3% of the nursing facilities had a hospice contract or agreement in place, these services were offered to only 72% of patients
• Of the 142 patients offered hospice care, only 95 accepted this offer
• 49.1% of physicians believed that dying patients' spiritual needs were met; most practitioners felt that their patients had a "good death"
• Physicians attributed their perceptions of a "good death" to freedom from pain, having family members at the bedside, being at peace, and having dignity intact
• In the few instances when the physicians perceived the patient's death not to be good, this often was attributed to factors outside of the practitioner's control-such as the patient's unwillingness to accept death.

"We were very pleased to hear that physicians are proactive about talking to patients regarding palliative care," Lieto noted. She also was pleased to discover that 92.9% of discussions occurred more than 48 hours prior to the patient's death. Most conversations actually took place nearly one month before the patient's demise. "It's enlightening to know that we aren't waiting for a crisis to have this discussion," she offered.