Intervention to Improve Care at Life's End in VA Medical Centers

Brief Summary

Detailed Description

The BEACON trial (Best Practices for End-of-Life Care for Our Nations' Veterans) was a six-site, real-world implementation trial of a multi-component, education-based intervention to improve the quality of end-of-life care conducted in VA Medical Centers (VAMCs). The primary aim was to evaluate the effectiveness of a multi-component intervention for improving processes of care provided in the last days of life in VAMCs. The second aim was to conduct after-death interviews with next-of-kin and qualitative analysis of their perceptions of the care provided to the veteran and family. The multi-component intervention targeted VAMC inpatient providers, including physician, nursing, and ancillary staff. It consisted of preparatory site visits, a staff training program, a newly developed Comfort Care order set decision support tool built into the CPRS, and follow-up consultation. The intervention team travelled to each site to conduct two weeks of comprehensive in-service training. Staff were trained to identify actively-dying patients and implement a set of best practices of traditionally home-based hospice care for dying patients. The team provided assistance with policies, procedures, and skill training needed to implement comfort care interventions. Introduction of the intervention at each VAMC was staggered across time at six-month intervals using a multiple-baseline, stepped wedge design. Data on processes of end-of-life care (last 7 days) were abstracted from the CPRS medical records of all veterans who died before, during, and after the intervention (January 2005-February 2011). A priori, five processes of care were identified as primary endpoints to indicate quality of end-of-life care: 1) presence of an order for opioid pain medication at time of death; 2) a do-not-resuscitate (DNR) order in place at time of death; 3) location of death; 4) presence of enteral feeding tube or intravenous line at time of death; and 5) physical restraints in place at or near time of death. In addition, in-depth, face-to-face interviews were conducted with 78 bereaved next-of-kin.

Primary Outcomes

Secondary Outcomes

• Number of Patients Who Died in ICU(Pre and Post Intervention)
• Individuals Administered of Opioid Medication(Pre and Post Intervention)
• Individuals With Pastoral Care Visit(Pre and Post Intervention)
• Individuals With a Palliative Care Consultation(Pre and Post Intervention)
• Do Not Resuscitate Order(Pre and Post Intervention)
• Individuals With a Nasogastric Tube(Pre and Post Intervention)
• Individuals With an Intravenous Line(Pre and Post Intervention)
• Number of Individuals Who Died in Restraints(Pre and Post Intervention)
• Individuals With an Order for Benzodiazepine Medication(Pre and Post Intervention)
• Individuals Who Received Benzodiazepine Medication(Pre and Post Intervention)
• Individuals With an Advance Directive(Pre and Post Intervention)
• Individuals With an Order for Antipsychotic Medication(Pre and Post Intervention)
• Sublingual Administration(Pre and Post Intervention)
• Individuals Administered Antipsychotic Medication(Pre and Post Intervention)
• Individuals Who Received Scopolamine(Pre and Post Intervention)