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Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment
Design and Participants: This retrospective chart review of a convenience sample assessed utilization and time to death for 12-month periods pre- and postoptimizing a withdrawal of life-sustaining treatment (WLST) order set used across hospitals in one not-for-profit healthcare system. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type or specialty, and COVID-19 status.
Results: In total,1,949 patients had orders placed via WLST and died in hospital. Versus 2017-2018, 2021-2022 use increased 36%. Time to death after release of orders was longer for 2021-2022 (4.4 vs 3.7 hrs). Nurse practitioners (39%) were the most frequent WLST utilizer, and 46% of terminal hospitalizations had palliative consultation. Among decedents with consultation, palliative clinicians were the WLST utilizer for 47% of cases (21% of utilizations). Median time to death was longer when orders were placed by palliative clinicians (4.5 hrs) vs nonpalliative specialists (3.9 hrs). COVID-19 was diagnosed for 29% of 2021-2022 decedents.
End-of-Life Outcomes Following Comfort Care Orders: A Single Center Experience
Design and Participants: This study performed a retrospective analysis of adults placed on comfort care (CC) at a university hospital, to better characterize the needs of this patient population and whether they can fully utilize hospice services. Each patient chart was analyzed for physician ordering CC order set, diagnosis, comorbidities, palliative care involvement, length of stay, number of hospitalizations, IV medications after order set, time of order, time of discharge, time of death, CC duration, and disposition. Descriptive analysis was performed.
Results: In total, 541 patients were included. A mean of 1.5 patients per day were placed on CC (median=1 day; median=2 days for subspecialty and hospital medicine patients). Overall, 78% died in hospital. Forty percent of non-ICU patients were discharged with hospice services. Sixty percent of patients were in the ICU and spent a median of 2.3 hours on CC; 19% of ICU patients were on CC for more than 12 hours. Additionally, 94% of patients placed on CC in the ICU died in-hospital vs 53% of subspecialty and 59% of hospital medicine patients.
Commentary: In combination, these studies outline end-of-life care in the hospital and highlight the need for processes to deliver quality care. Coincidentally, both studies report a slight minority (46%, 48%) of patients receiving specialty palliative care (PC). This is important considering symptom management (82% of patients in Tucker et al’s study received IV pain medication) and care planning (40% of non-ICU patients were discharged with hospice) needs in the hours to short days between comfort orders and death. Grable et al suggest PC involvement in intelligent and adaptive order set design while Tucker et al advocate for expanding access to inpatient hospice. These studies reflect localized practices, such as the lack of in-hospital general inpatient hospice as an option, but offer generalizable insights.
Bottom Line: Palliative care clinicians may expand access to improved end-of-life care by supporting changes in comfort care practices at the health system level.
Reviewer: Jared Lowe, MD HMDC, University of North Carolina School of Medicine, Chapel Hill, NC
References:
1. Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life. Intensive Care Med. 2008;34(9):1593-1599; doi:10.1007/s00134-008-1172-y.
2. Bodnar J. Terminal withdrawal of mechanical ventilation: a hospice perspective for the intensivist. J Intensive Care Med. 2019;34(2):156-164; doi:10.1177/0885066618797918.
Sources:
Grable S, McKeon S, Burns B, Wetshtein A, Rossfeld Z. Observations from optimizing an electronic order set for withdrawal of life-sustaining treatment. J Palliat Med. 2024;27(7):846-853. doi:10.1089/jpm.2023.0380.
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Tucker M, Hovern D, Liantonio J, Collins E, Binder AF. End of life outcomes following comfort care orders: a single center experience [online ahead of print May 13, 2024]. Am J Hosp Palliat Care. doi:10.1177/10499091241253561.
Access this article on PubMed.