ONS Connections: Implementing an end-of-life pathway enhances quality care

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PHOENIX—Nurses implemented an end-of-life pathway that enhanced the ability of oncology nurses to provide high quality care at a crucial time for patients and families, according to research presented at the Oncology Nursing Society (ONS) Connections: Advancing Care Through Science conference.

A multidisciplinary task force was appointed by the James Cancer Hospital Quality Committee to improve end-of-life care for hospitalized patients. The team chose a clinical pathway because of research indicating that it improves quality care, uses resources more effectively, and enhances satisfaction. The team created a computerized order set, a nursing documentation flowsheet, and a summary instruction document. Nurse education sessions were unit-based, plus a Nursing Grand Rounds was included. The Ground Rounds featured Marilyn Bookbinder, PhD, who shared her experiences with end-of-life pathways.

The program began in pilot form in late 2010 in the unit that had the most deaths and discharges to hospice. The project was expanded to two more nursing units, and it was subsequently endorsed by the hospital board as a primary quality initiative for an additional 2 years. The eventual goal is to implement the program throughout the cancer hospital. Further, the program has attracted interest at the level of the health system, with the desire to spread it through all inpatient facilities.

Nurses contributed to the Advanced Cancer Care Pathway by envisioning, designing, teaching, and implementing it. Nurses often led at every step. Implementing the end-of-life pathway means oncology nurses have an enhanced ability to provide high quality care.

Several challenges to nurse implementation of the pathway were identified, said Elizabeth Arthur, RN, CNP, MSN, AOCNP, during a presentation of the research at ONS Connections. Among them were provider fear that patients/families would perceive abandonment; provider delay of the pathway if the patient was not immediately enrolling in hospice or if the patient would be discharged soon; hesitancy to take ownership of the responsibility to communicate with the patient/family; and educating busy, rotating physicians.

After the program was implemented, only 33% of eligible patients were enrolled, indicating the need to evaluate and include all qualified patients; 6 of 10 quality goals were met. The average length of stay was reduced to approximately 6.5 days with the pathway compared with 10 or more days with standard care, said Arthur, and the direct and indirect costs of care decreased.

Discharges to hospice increased from 54% to 66% with the end-of-life pathway, and the number of customer service complaints was reduced. In addition, family satisfaction with the program was 86.7%. The researchers found that the pathway ensured a strong nursing presence during all stages and empowered nurses with the tools they needed to provide higher quality end-of-life care. In addition, the tool could be used to educate providers.

Future research will explore such patient-centered outcomes as symptom management, transitions to home, and satisfaction from patients and families. The program may also impact system outcomes that may include hospital length of stay, healthcare cost, and staff satisfaction.

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