Evidence-Based Practice

in End of Life Care

By: Kyra Barstad, Julia Binder, Chloe Dewitt, Angelica Painter, Bella Rahal, Daniel
Reavis, Haley Small, Kayla Sonderman, Lindsay Weigel

Lab Group A
Introduction
● What is End of Life care?
○ Hospice Care vs. Palliative Care
● In what setting does End of Life care occur?
○ Home, hospice, nursing home, hospital
● When do people receive it?
○ Transition away from traditional hospital ● Significance to Nursing
curative care. Focus on comfort and holistic ○ Role of nurses in palliative and end of life care
needs of patient ■ Advocacy and Communication
● Who is involved in care? ■ Nurses know the patient!
○ Multi-disciplinary team
(National Institute of Health, 2017) (Hagan, Xu, Lopez, & Bressler, 2018)
PICOT Question

In patients receiving end-of-life care what is

the effect of home-based hospice care
compared to inpatient hospice care on
patient and family satisfaction?
Summary of Current Practice

National
● End-of-life care established within the Medicare Hospice Benefit
○ Hospice certification: must include medical, nursing, social work, chaplaincy, and
bereavement support
● 41% of hospice care patients receive care at home, 22% inpatient hospice
● Growth of hospital palliative care teams
(Morrison, 2015)
Summary of Current Practice
State
● Palliative care teams in hospitals
● Adheres to National guidelines established in Hospice Medicare Benefit
○ Additional state requirements - such as licensure through Joint Commission
(Morrison, 2015)
Local (St. Joseph’s Hospital)
● No specific palliative care team, but physicians and case managers guide patients and families through
available options
● No specific training for nurses
● Focus of care changes to comfort measures and controlling pain
● Nurses act as resources for the patient and family
Synopsis of Research
● Main findings:
○ No matter the setting, patient-family satisfaction determined to be equal
○ Four main variables:
■ Information about patient, consistency, spiritual care, and anxiety reduction
○ Earlier intervention associated with
■ greater satisfaction
■ decreased cost to patient and hospital
○ Nurse education associated with greater confidence and patient satisfaction
● Levels of evidence from III-VI
○ Cross-sectional studies, cohort studies, quasi-experimental studies
Strengths and Limitations of Research
Strengths
● Peer reviewed
● Complementary & refined
● Easy to analyze

Limitations
● Sample size
● Findings may not be reproduced
● Data collection
Evidence Based Recommendations
Research findings:
● Hospice patients and their families were equally satisfied in both home
hospice and inpatient hospice settings
○ Factors that cause increased patient and family satisfaction:
■ Patient information
■ Consistency in care
■ Spiritual care
■ Anxiety reduction

Integration with Guidelines for Best Practice:

● National guidelines for hospice patient care should align with factors that
increase patient/family satisfaction in research
Guidelines for Best Practice
● Assess
○ Contributing diagnoses, medical history
○ Psychiatric state, social support, familial support, spiritual and cultural values,
and financial need
● Advocate
○ On behalf of assessed needs, values, goals, and expectations
● Educate
○ Continuing nursing education to meet standard of care
○ Patient and family member referrals
● Collaborate
○ Involve all members of healthcare team
● Intervene
○ Symptom management as ordered, therapeutic communication

(National Consensus Project for Quality Palliative Care, 2018)

Integration of Evidence and Best
Practice
● Research:
○ Setting in which patients receive hospice care did not have a clear statistical difference in patient
or family satisfaction
○ Factors that do improve patient satisfaction support current best practice hospice nursing care
● Integration:
○ Adherence to hospice care protocol after patient hospice referral yields the most satisfaction.
 Overall Application and
Implementation to Nursing
● Policy development - January 10, 2020
○ Palliative care team works with ICU nursing management to create a policy
○ Policy development meetings will occur once a week through February 10,
2020
● Nursing education - February 10, 2020
○ Mandatory training for ICU nurses will be available for two weeks
○ Training will begin February 10 and last through February 28
○ Nurses are required to attend 15 hours of online training modules during
this time
● Implementation to nursing practice - March 1, 2020
○ Nurses will implement the knowledge they gained through nursing
education on caring for patients in hospice care

(National Consensus Project for Quality Palliative Care, 2018)

 (Hasbro Monopoly Money, 2019)

Cost Analysis: Implementation

Training Cost Application of cost at St. Joseph’s

● Online Course Training (OCT): ● Number of ICU nurses:

○ $199 Per person ○ +/- 42 x $199
■ +/- $8,358

Cost Analysis: Comparison
Hospital Cost
● Virtual Reality Training (VRT):
○ $ 327.78 per person
○ $106,951.14 Total
■ 57 employees
● Live Drill Training (LDT):
○ $229.75 per person
○ $18,617.54 Total
■ 57 employes
(VR-Training, 2019)
Cost Findings
● Training all NICU nurses using LDT
would cost $76,650.02 for the first
year.
○ LDT has a constant re-training
price.
● Training all U nurses using VRT would
cost $109,747.97 for the first year
○ VR re-training cost $3090.97
(May, Et al., 2015)
Cost Analysis: Patient Savings
Patient Savings
● Late education and Intervention
○ stayed in the hospital an average
of 9.5 days
○ variable direct cost of $17,444 per
case.
● Early Education and Intervention
○ stayed in the hospital less than
two days
○ direct cost variable of $1,017 per
case.
● Difference in cost
○ $16,427
(Fermia, & Et al., 2016)
Decreased Hospital Cost
(compared to no intervention)
● Intervention within six days
○ $1,312 per patient
● Intervention two days
○ $2,280 per patient
● Cost saving implied is 14% of total
direct hospital costs for a consult
within 6 day and 24% within two
days!
(May, Et al., 2015)
Cost Analysis: Importance of
Implementation
● Long term hospital cost savings
● Patient cost savings
● Increased patient satisfaction

(Sullender Et al., 2016)

(Win-Win, 2014)
 Risk vs. Benefit Based on Research: Home-Based
Hospice Care
● Risk of home-based hospice:
○ Advanced level of care is needed (Ong, Brennsteiner, Chow, & Hebert, 2016).

● Benefit of home-based hospice:

○ The patient has the ability to die at home (Bainbridge & Seow, 2018).
○ Decreased cost burden (Chiang & Kao, 2016).
○ Spiritual & cultural needs were met fully (Unroe, Stump, Effler, Tu & Callahan,
2018).
Risk vs. Benefit Based on Research: Inpatient
Hospice Care
● Risk of inpatient hospice:
○ Increased cost related to time spent in the hospital (Fermia, Wilkins, Rodriguez,
Read, Gavin, & Caspers, 2016).
○ Less likely to report receiving excellent care compared to those receiving care at
home (Unroe, Stump, Effler, Tu, & Callahan, 2018).
○ Less likely to feel the death of the patient occured in a setting of their choice (Unroe,
Stump, Effler, Tu, & Callahan, 2018).
○ Increased burden on family (Chiang & Kao, 2016).
● Benefit of inpatient hospice:
○ Family feels everything is being done to keep their loved one comfortable (Fermia,
Wilkins, Rodriguez, Read, Gavin, & Caspers, 2016).
Evaluation: SMART Outcomes
Hospital
The hospital will implement a comprehensive hospice education module into annual
education/training for all ICU nurses by February 28th, 2020.
Nursing Staff
All ICU nurses will report understanding their role during the transition to hospice care and
feeling confident in their ability to perform these duties upon completion of the training module.
Patients/Families
Patient and family satisfaction with end of life care will increase after staff receives the hospice
training as evidenced by higher satisfaction scores on discharge surveys.
Summary
● Introduction
● Description of issue
● Supportive studies
● Best practice
● Application to facility
● Cost analysis
● Risk vs. benefit
Summary

PICOT: In patients receiving end-of-life care what is the effect of home-based

hospice care compared to inpatient hospice care on patient and family satisfaction?

As a group and based on research we feel confident in stating that patient and family
satisfaction is consistent throughout home-based hospice and inpatient hospice
care. However, with the implementation of this intervention, satisfaction rates will
continue to improve in the future.
Questions???
Thank you!
References
Bainbridge, D., & Seow, H. (2018). Palliative care experience in the last 3 months of life: A quantitative comparison of care provided in residential

hospices, hospitals, and the home from the perspectives of bereaved caregivers. American Journal of Hospice & Palliative Medicine,

35(3), 456-463. doi: 10.1177/1049909117713497 journals.sagepub.com/home/ajh

Chiang, J. K., & Kao, Y. H. (2016). Impact of home hospice care on patients with advanced lung cancer: A longitudinal population-based study in

Taiwan. J Palliat Med, 19(4), 380-386. doi:10.1089/jpm.2015.0278

Fermia, R., Wilkins, C., Rodriguez, D., Read,K., Gavin, N., & Caspers, C. (2016). Cost savings and palliative care referrals from the emergency

department. Physician Leadership Journal, 3(5), 8-11. Retrieved from https://link-gale-

com.ezproxy1.library.arizona.edu/apps/doc/A464450068/AONE?u=uarizona_main&sid=AONE&xid=7447da95

Farra, S., Gneuhs, Hodgson, E., M., Kawosa, B., Miller, E., Simon, A., Timm, N., & Hausfeld, J. (2019). Comparative Cost of Virtual Reality

Training and Live Exercises for Training Hospital Workers for Evacuation. Computers, Informatics, Nursing, 37(9): 446-454. doi:

10.1097/CIN.0000000000000540
References
Hagan, T. L., Xu, J., Lopez, R. P., & Bressler, T. (2018). Nursing's role in leading palliative care: A call to action. Nurse Educ Today, 61, 216-219.

doi:10.1016/j.nedt.2017.11.037

Hasbro Monopoly Money. (2019). Retrieved from: https://www.amazon.com/Hasbro-28852-Monopoly-Money/dp/B00000IWCW

Johnson, S., & Bott, M. J. (2016). Communication With Residents and Families in Nursing Homes at the End of Life. Journal of Hospice &

Palliative Nursing, 18(2), 124–130. doi: 10.1097/njh.0000000000000222

May, P., Garrido, M., Cassel, J., Kelley, A., Meier, D., Normand, C., Smith, T., Stefanis, L., & Morrison, S. (2015). Prospective cohort study of

hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. Journal

of Clinical Oncology, 33(25), 2745-2752. doi: 10.1200/JCO.2014.60.2334

Morrison, R. S. (2015). Models of palliative care delivery in the United States. Curr Opin Support Palliat Care, 7(2), 201-206.

doi:10.1097/SPC.0b013e32836103e5

National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA:

National Coalition for Hospice and Palliative Care; 2018. https://www. nationalcoalitionhpc.org/ncp.
References
National Institute of Health (2017). What are palliative care and hospice care? Retrieved from

https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care#hospice

Kerr, C. W., Donohue, K. A., Tangeman, J. C., Serehali, A. M., Knodel, S. M., Grant, P. C., Luczkiewicz, D. L., Mylotte, K., & Marien, M. J.

(2014). Cost savings and enhanced hospice enrollment with a home-based palliative care program implemented as a hospice–private

payer partnership. Journal of Palliative Medicine, 17(12), 1328-1335. doi: 10.1089/jpm.2014.0184

Ong, J., Brennsteiner, A., Chow, E., & Hebert, R. (2016). Correlates of family satisfaction with hospice care: General inpatient hospice care versus

routine home hospice care. Journal of Palliative Medicine, 19(1), 97-100. doi: 10.1089/jpm.2015.0055

Pterusdottir, A. B., Haraldsdottir, E., & Svavarsdottir, E. K. (2018). The impact of implementing an educational

intervention to enhance a family‐oriented approach in specialised palliative home care: A

quasi‐experimental study. Scandinavian Journal of Caring Sciences, 33(2), 342-350. doi:

org.ezproxy3.library.arizona.edu/10.1111/scs.12628.
References

Shiley Institute for Palliative Care. (2019). Integrating Advance Care Planning into Your Medical Practice. Retrieved from:

https://csupalliativecare.org/programs/advance-care-planning/integrating/

Sullender, R. & Selenich, S. (2016). Financial Considerations of Hospital-Based Palliative Care. RTI Press, Research Triangle Park, NC. doi:

10.3768/rtipress.2016.rr.0027.1603

Thomas, T., Clarke, G., & Barclay, S. (2018). The difficulties of discharging hospice patients to care homes at

the end of life: A focus group study. Palliative Medicine, 32(7), 1267–1274.

https://doi-org.ezproxy4.library.arizona.edu/10.1177/0269216318772735

Unroe, K. T., Stump, T. E., Effler, S., Tu, W., & Callahan, C.M. (2018). Hospice quality of care in home vs. assisted living facility vs. nursing home

settings. Journal of the American Geriatrics Society, 66(4), 687-692. doi: 10.1111/jgs.15260

Win-Win. (2014). Retrieved from: https://www.psychologytoday.com/us/blog/happiness-purpose/201407/happiness-others-practice-win-win