0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation | Health Care Reform

The Optimal Delivery of Palliative Care:  A National Comparison of the Outcomes of Consultation Teams vs Inpatient Units FREE

David Casarett, MD, MA; Megan Johnson, BA; Dawn Smith, MS; Diane Richardson, PhD
[+] Author Affiliations

Author Affiliations: Division of Geriatric Medicine, School of Medicine, University of Pennsylvania (Dr Casarett), and Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center (Mss Johnson and Smith and Dr Richardson), Philadelphia.


Arch Intern Med. 2011;171(7):649-655. doi:10.1001/archinternmed.2011.87.
Text Size: A A A
Published online

Background  Growing attention to end-of-life care has led to intensive efforts to provide better palliative care. However, it is not known whether palliative care is best provided by consultative teams or in dedicated units.

Methods  This nationwide telephone survey was conducted in 77 Veterans Affairs medical centers that offer palliative care consultation services and dedicated palliative care units. One family member per patient who died at a participating Veterans Affairs medical center between July 1, 2008, and December 31, 2009, was invited to participate. The telephone survey included 1 global rating item and 9 core items describing the patient's care in the last month of life.

Results  Interviews were completed with family members for 5901 of 9546 patients. Of these, 1873 received usual care, 1549 received a palliative care consultation, and 2479 received care in a palliative care unit. After nonresponse weighting and propensity score adjustment, families of patients who received a palliative care consultation were more likely than those who received usual care to report that the patient's care in the last month of life had been “excellent” (adjusted proportions: 51% vs 46%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02-1.55; P = .04). However, families of patients who received care in a palliative care unit were even more likely to report excellent care (adjusted proportions: 63% vs 53%; OR, 1.52; 95% CI, 1.25-1.85; P < .001).

Conclusion  Care received in palliative care units may offer more improvements in care than those achieved with palliative care consultations.

Although most Americans prefer to die at home,14 the majority die in inpatient settings. In 2005, approximately 29% of Medicare deaths in the United States occurred in an acute care hospital and 72% of those patients were hospitalized at least once in the last month of life.5 In addition, approximately 25% of patients die in nursing homes,6 a number that is likely to increase.7

Growing attention to end-of-life care has identified numerous problems with inpatient settings. For instance, many patients experience uncontrolled symptoms near the end of life.810 In addition, communication regarding patients' illness and treatment is often insufficient,1115 and both patients and their families may not receive the emotional support they need.10,1618 Together, these problems contribute to families' negative assessments of end-of-life care.1923 To address these problems, hospitals and nursing homes have increasingly developed palliative care consultation teams.2430 According to a survey conducted in 2008,31 31% of all US hospitals now provide some form of palliative care.

There also has been growing interest in distinct palliative care units.32 These units rely on dedicated staff to provide tertiary palliative care33 and are analogous to dedicated intensive care units.32,34,35 Palliative care units offer the potential to improve end-of-life care substantially. However, it is not known whether these units provide better care than a consultation team does. This question is important because dedicated palliative care units are resource intensive and require hospitals and nursing homes to make a substantial investment. Therefore, the goal of this study was to compare the effect of palliative care consultation teams with that of dedicated palliative care units on the quality of care in a national sample of hospitals and nursing homes in the Department of Veterans Affairs (VA) integrated health care system.

SAMPLE AND SETTING

Of 140 VA inpatient facilities in the United States and Puerto Rico, we analyzed those (n = 77) with both palliative care consultation services and palliative care units. Because hospitals that had units also had consultation teams (but not vice versa), we reasoned that these hospitals have well-developed palliative care programs. Therefore, they represent a sample that is relatively homogeneous with respect to palliative care resources. Patients who died in one of these facilities were identified using the VA's electronic medical record system. Medical record reviews were also used to confirm eligibility, define key patient characteristics (eg, age, ethnicity, and site of death), and identify the process of care that the patient received at the time of death (ie, usual care, palliative care consultation, or palliative care unit).

We excluded the records of patients who died as a result of suicide or accident and those who died within 24 hours of admission to the institution or in the emergency department, unless they had been admitted to a VA facility in the preceding month. During infrequent periods when the number of deaths exceeded interviewing capacity, patient records were selected at random for omission. For each patient, a family member was identified based on the VA's policy of death notification: (1) next of kin; (2) primary contact named in the electronic medical record; and (3) durable power of attorney for health care.

Four weeks after the patient's death, we sent an introductory letter to the family that included a toll-free telephone number that they could use to refuse to participate. Interviewers then made up to 3 telephone calls, including at least 1 after 5 PM local time Monday through Friday or on the weekend. We excluded family members who did not speak English or Spanish as well as those with a hearing impairment or other health condition that precluded a telephone interview. We also excluded family members who said they could not evaluate the care that the patient received in the last month of life; we asked them to identify a more knowledgeable informant, who was then contacted. At the conclusion of each telephone survey, families were asked whether they would like to be referred to a counselor for bereavement support or to a hospital representative for other questions or concerns. If, after 3 attempts, the interviewer was unable to reach the family member, or if a health condition precluded a telephone interview, we mailed an identical survey that was labeled to allow matching of the survey to the patient.

All surveys consisted of the short version of the Family Assessment of Treatment at End-of-Life, whose development, validity, and psychometric properties have been described.20,30,36,37 The survey has English and Spanish versions, both of which contain 10 core items (Table 1). Nine items measure specific aspects of care and use frequency-based response options whose scores are dichotomized as 1 for the best possible response or as 0 for all other responses. The 10th item, which asks families to evaluate the care that the patient received in the last month of life (poor, fair, good, very good, or excellent), is scored as excellent vs all other responses. We used this so-called top box scoring method to reduce the ceiling effects that are commonly observed in satisfaction surveys.

To account for potential nonresponse bias, we evaluated patient and family characteristics as potential predictors of survey completion (Table 2). Next, we used a multivariable logistic regression model to predict the likelihood of a completed survey for each patient in the sample, checking its performance by calculating the area under the receiver operating characteristic curve. For this and all subsequent models, we used robust jackknife standard errors, clustered by facility, including all variables that were independent predictors and adding additional variables to achieve the model with the lowest possible information criterion value.38 We then calculated a weight for each completed survey (the inverse of the probability that that survey would be completed). Thus, groups of patients who were underrepresented in the sample were assigned a higher weight. We checked the appropriateness of the model by comparing the weighted sample characteristics with the characteristics of the entire population.

Table Graphic Jump LocationTable 2. Characteristics of Patients Receiving Usual Care, Care From a Palliative Care Consultation Team, and Care in a Palliative Care Unit

Next, we used propensity scores to account for nonrandom assignment among groups by constructing 2 separate logistic regression models (palliative care consultation vs usual care and palliative care unit vs palliative care consultation). For each pair, we first built a limited model that included only patient characteristics reported in Table 2 that were independently associated with group assignment. We then added variables systematically in all possible combinations and selected the one with the lowest Akaike information criterion.38 We used this model to predict group assignment in each pair and then used each patient's propensity score to adjust the characteristics of the patients in each pair of groups. When groups were not balanced, additional characteristics were added to the model and balance was rechecked until the 2 models balanced all characteristics reported in Table 2.

Using nonresponse weights and propensity score adjustments, we compared the global item scores and individual item scores between usual care and palliative care consultations, and between palliative care consultations and palliative care units. These regression models also used robust jackknife standard errors, clustered by facility. Stata statistical software (Stata for Windows, version 10.0; StataCorp LP, College Station, Texas) was used for all analyses. We planned a sample of at least 1500 patients in the smallest of 3 groups (usual care, palliative care consultation, or palliative care unit) to provide adequate power to detect a 6% difference in the proportions of families reporting excellent care (1 − β = .84; α = .025, adjusted for multiple comparisons). Because this project was conducted as part of the VA's operations and was designed primarily to provide VA hospitals with actionable quality data, institutional review board approval was not sought for data collection. An application for secondary use of these data for publication was granted an exemption by the institutional review board of the Philadelphia VA Medical Center.

Medical record review identified 16 158 patients who died in 1 of 140 participating VA facilities between July 1, 2008, and December 31, 2009. We restricted this sample to 77 facilities that had both palliative care consultation teams and inpatient palliative care units. These 77 facilities were larger than those excluded (mean, 409 vs 272 beds; rank sum test, P < .001), had more inpatient admissions per year (mean, 9662 vs 6718; rank sum test, P < .001), and had more deaths per month (mean, 14.6 vs 8.1; rank sum test, P < .001). Patients from included and excluded facilities were similar, except that patients who died in facilities that were included were more likely to have cancer (51% vs 46%; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.06-1.45; P = .006) and less likely to have kidney disease (38% vs 43%; OR, 0.78; 95% CI, 0.65-0.94; P = .009).

At these 77 facilities, 10 633 patients who died within the study period were identified. Of these patients' family members, a total of 1087 were ineligible because they did not have a working telephone number or valid address (n = 1023) or there was no eligible respondent available (n = 64). Interviews could not be completed with 2630 eligible family members because they did not answer the telephone or return a mailed survey, and 642 family members refused an interview. In addition, 164 family members did not have adequate knowledge about the patient's last month of life, 74 were reluctant to talk about the patient's death, and 31 had health conditions that precluded an interview. Twelve respondents were excluded because they spoke neither English nor Spanish.

Surveys were completed with the remaining 5993 families. Of these, 92 did not complete the entire survey, 4946 completed a telephone survey, and 955 completed a mailed survey. Mailed surveys and telephone interviews had similar scores, so their results were combined, producing a final sample of completed surveys for 5901 participants (61.8% of the 9546 who were eligible). Response rates were similar in the 2 palliative care groups, but were lower in the usual care group (palliative care consultation, 66.3%; palliative care unit, 64.8%; usual care, 51.3%).

In the optimal model of survey completion, the following characteristics were associated with response: diagnosis of dementia or chronic lung disease, white race, do-not-resuscitate order at the time of death, death in an intensive care unit, documented discussion with a family member, interview with the patient's spouse (vs other relationships), and documented family contact with a chaplain or bereavement counselor. This model was homogeneous across the 3 treatment groups, producing weights that ranged from 1.25 to 4.08. After response weights were applied, all survey sample characteristics were within 1% of those of the entire sample, except for the proportion of patients with dementia (17.6% in the entire sample vs 19.3% in the weighted survey sample).

Of patients reported in the 5901 completed surveys, 1873 received usual care, 1549 received a palliative care consultation, and 2479 died in a palliative care unit (Table 2). Two propensity score models were generated to predict assignment in each of the 2 pairs (usual care vs palliative care consultation and palliative care consultation vs palliative care unit). Variables included in the model predicting palliative care consultation vs usual care included site of care (medical/surgical ward, intensive care unit, nursing home), age (in 10-year increments), race (white vs other), and diagnoses of cancer, heart failure, and coronary artery disease. Variables included in the model predicting care in a palliative care unit vs palliative care consultation included age (in 10-year increments), race (white vs other), respondent relationship (spouse vs other), and diagnoses of cancer, dementia, kidney disease, and coronary artery disease. After adjusting for a propensity score based on these variables, the 2 pairs of groups were balanced within 1% with respect to all variables reported in Table 2.

PALLIATIVE CARE CONSULTATION vs USUAL CARE

Families of patients who received a palliative care consultation were more likely than those of patients who received usual care to report that the patient's care in the last month of life had been excellent (adjusted proportions: 51% vs 46%; OR, 1.25; 95% CI, 1.02-1.55; P = .04) (Table 3). Significant differences were found for 7 items, of which the largest effect sizes were noted for the degree to which providers gave enough spiritual support (adjusted proportions: 52% vs 45%; OR, 1.36; 95% CI, 1.15-1.61; P = .001) and emotional support (adjusted proportions: 57% vs 49%; OR, 1.35; 95% CI, 1.14-1.60; P = .001) before the patient's death. No significant differences were found for 3 items, including pain management (adjusted proportions: 26% vs 29%; OR, 0.84; 95% CI, 0.66-1.07; P = .15), assistance with funeral arrangements (adjusted proportions: 67% for both; OR, 1.00; 95% CI, 0.87-1.16; P = .98), and emotional support after the patient's death (adjusted proportions: 59% vs 54%; OR, 1.20; 95% CI, 1.00-1.43; P = .05) (Table 3).

Table Graphic Jump LocationTable 3. Effect of Palliative Care Consultations and Palliative Care Units

Patients who received palliative care consultations were more likely than those who received usual care to have a do-not-resuscitate order documented at the time of death (adjusted proportions: 95% vs 76%; OR, 5.41; 95% CI, 4.18-7.02; P < .001) and were more likely to have a documented chaplain visit (adjusted proportions: 39% vs 24%; OR, 2.04; 95% CI, 1.69-2.47; P < .001). Patients who received palliative care consultations were also more likely to have had a documented discussion of goals of care in the last month of life (adjusted proportions: 95% vs 85%; OR, 3.64; 95% CI, 2.68-4.95; P < .001). Families of patients who received palliative care consultations were also more likely to receive a bereavement contact after the patient's death (adjusted proportions: 18% vs 12%; OR, 1.60; 95% CI, 1.19-2.17; P = .002).

PALLIATIVE CARE UNITS vs PALLIATIVE CARE CONSULTATIONS

Compared with families of patients who received a palliative care consultation, families of patients who received care in a palliative care unit were more likely to report that the patient's care in the last month of life had been excellent (adjusted proportions: 63% vs 53%; OR, 1.52; 95% CI, 1.25-1.85; P < .001) (Table 3). Among specific items, the largest effect size was found for emotional support before the patient's death (adjusted proportions: 67% vs 57%; OR, 1.53; 95% CI, 1.26-1.86; P < .001), and slightly more modest effects were found for spiritual support (adjusted proportions: 62% vs 53%; OR, 1.45; 95% CI, 1.21-1.73; P < .001) and emotional support after the patient's death (adjusted proportions: 68% vs 59%; OR, 1.45; 95% CI, 1.18-1.79; P = .001). Only pain management did not show a benefit of care in a dedicated palliative care unit (adjusted proportions: 24% vs 26%; OR, 0.90; CI, 0.73-1.11; P = .32).

Patients in palliative care units were more likely than those who received palliative care consultations to have a do-not-resuscitate order at the time of death (adjusted proportions: 98% vs 95%; OR, 3.11; 95% CI, 2.21-4.37; P < .001) and were more likely to have a documented chaplain visit (adjusted proportions: 45% vs 38%; adjusted OR, 1.35; 95% CI, 1.22-1.62; P < .001). They were not more likely to have a documented discussion of goals of care in the last month of life (96% vs 95%; adjusted OR, 1.35; 95% CI, 0.94-1.95; P = .108) but were more likely to receive a bereavement contact after the patient's death (35% vs 18%; adjusted OR, 2.22; 95% CI, 1.53-3.23; P < .001).

Although most people would prefer to die at home, the majority will die in inpatient settings. Therefore, it is essential to identify ways that end-of-life care can be improved for patients who die in hospitals and nursing homes. This study offers 2 key findings that should guide the development of programs to care for these patients.

First, these results provide convincing evidence that palliative care consultations are effective in improving the quality of care for patients near the end of life. For instance, palliative care consultations are associated with important processes of care (eg, goal discussions, chaplain support) and improved families' perceptions of outcomes. Previous studies have documented a positive effect in circumscribed settings or in the context of controlled clinical trials.2830,3942 Our study provides valuable evidence of the effect that palliative care consultations can have across a wide range of hospitals in a nationwide sample. These results confirm that palliative care consultations can play a key role in improving care of patients who die in hospitals and nursing homes.

Second, this study found that care in a palliative care unit offers significant advantages compared with a palliative care consultation. Indeed, for almost every aspect of care assessed, families reported better outcomes when the patient received care in a palliative care unit than they did when the patient received a palliative care consultation. Three of 4 process measures were also improved. The fourth, goal discussions, occurred at such a high rate among patients who received palliative care consultations that further improvement would be difficult to achieve.

Therefore, it is possible that dedicated palliative care units offer substantial advantages over consultative palliative care. These units are equipped to provide continuous palliative care and typically have protocols and order sets that ensure a standard of care independent of physician coverage.32,34,35,43 In addition, these units have staff with specific training in palliative care, including the Education in Palliative and End-of-Life Care and End-of-Life Nursing Education Consortium programs. These units already exist for many hospices, and consideration should be given to including them in plans to improve the end-of-life experience for patients who die in other inpatient settings.

However, the benefits of palliative care consultations and inpatient units were not observed across all domains of care. These results should not be surprising, as studies in more limited settings have noted that palliative care consultations may have a greater effect on some aspects of care than on others.30,3941,44,45 It is possible that some aspects of care (eg, emotional support for families after death) require more time and resources than most palliative care teams have. It is also possible that patients and families with greater needs for care (eg, patients with severe pain) are more likely to receive a consultation and are more likely to be referred to a palliative care consultation team or inpatient unit. In the present study, we were unable to adjust for pain severity or other markers of palliative care needs. Therefore, this possibility should be evaluated in future research.

This study has 3 limitations. First, because veterans using VA resources tend to be older men, the study sample is one that is demographically atypical of the general US population.46 However, there is no reason to expect that the effect described here of palliative care consultations and palliative care units would be markedly different in another population.

Second, these results rely mostly on families' perceptions of care. Families may not always be able to assess the quality of care accurately. Nevertheless, they can offer a valuable perspective. Moreover, in the current study, an evaluation of families' perceptions and process measures both suggest the superiority of inpatient units, lending support to the usefulness of families' views of care.

Third, this study used techniques of weighting and propensity score adjustment to account for nonresponse bias and nonrandom assignment, respectively. These techniques are widely accepted and are being used increasingly in health services research. Nevertheless, their effectiveness depends on the accurate measurement of variables of interest, and there is always the possibility that other, unmeasured characteristics might have altered the results we report.

As increasing attention focuses on improving the quality of care that patients receive at the end of life, it will be essential to develop mechanisms of care that are effective and evidence based. The results reported here suggest that the palliative care consultation teams that are in widespread use offer substantial benefits to patients and their families. However, dedicated units may be even more effective. Creation of dedicated palliative care units that were included in this study has been possible only because the VA has invested substantially in the development of palliative care infrastructure, including staffing and construction. In other settings, a business case will need to be made that these units improve quality and decrease costs. Therefore, before such units are widely adopted, more research is needed to demonstrate that they are cost-effective.

Correspondence: David Casarett, MD, MA, Division of Geriatric Medicine, School of Medicine, University of Pennsylvania, 3615 Chestnut St, Philadelphia, PA 19104 (Casarett@mail.med.upenn.edu).

Accepted for Publication: October 25, 2010.

Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Casarett. Acquisition of data: Johnson and Smith. Analysis and interpretation of data: Casarett, Johnson, Smith, and Richardson. Drafting of the manuscript: Casarett, Johnson, Smith. Critical revision of the manuscript for important intellectual content: Casarett, Johnson, Smith, and Richardson. Statistical analysis: Smith and Richardson. Obtained funding: Casarett. Administrative, technical, and material support: Casarett and Johnson. Study supervision: Casarett.

Financial Disclosure: None reported.

Funding/Support: This material is based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Human Services Research and Development. This work was funded as part of a grant from the Department of Veterans Affairs Comprehensive End-of-Life Care Initiative (Dr Casarett).

Disclaimer: The contents do not represent the views of the Department of Veterans Affairs or the US government.

Brazil  KHowell  DBedard  MKrueger  PHeidebrecht  C Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med 2005;19 (6) 492- 499
PubMed Link to Article
Fried  TRvan Doorn  CO’Leary  JRTinetti  MEDrickamer  MA Older persons' preferences for site of terminal care. Ann Intern Med 1999;131 (2) 109- 112
PubMed Link to Article
Higginson  IJSen-Gupta  GJA Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 2000;3 (3) 287- 300
PubMed Link to Article
Tang  ST When death is imminent: where terminally ill patients with cancer prefer to die and why. Cancer Nurs 2003;26 (3) 245- 251
PubMed Link to Article
 End of life care. Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18. Accessed June 28, 2010
 Facts on dying: policy relevant data on care at the end of life: USA and state statistics. http://www.chcr.brown.edu/dying/2001DATA.HTM. Accessed June 30, 2010
Brock  DBFoley  DJ Demography and epidemiology of dying in the U.S. with emphasis on deaths of older persons. Hosp J 1998;13 (1-2) 49- 60
PubMed Link to Article
Mitchell  SLTeno  JMKiely  DK  et al.  The clinical course of advanced dementia. N Engl J Med 2009;361 (16) 1529- 1538
PubMed Link to Article
Hanson  LCDanis  MGarrett  J What is wrong with end-of-life care? opinions of bereaved family members. J Am Geriatr Soc 1997;45 (11) 1339- 1344
PubMed
Teno  JMClarridge  BRCasey  V  et al.  Family perspectives on end-of-life care at the last place of care. JAMA 2004;291 (1) 88- 93
PubMed Link to Article
Wright  AAZhang  BRay  A  et al.  Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300 (14) 1665- 1673
PubMed Link to Article
Hofmann  JCWenger  NSDavis  RB  et al. SUPPORT Investigators, Patient preferences for communication with physicians about end-of-life decisions. Ann Intern Med 1997;127 (1) 1- 12
PubMed Link to Article
Curtis  JRPatrick  DLCaldwell  EGreenlee  HCollier  AC The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians. AIDS 1999;13 (9) 1123- 1131
PubMed Link to Article
McDonagh  JRElliott  TBEngelberg  RA  et al.  Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med 2004;32 (7) 1484- 1488
PubMed Link to Article
Higginson  IJFinlay  IGGoodwin  DM  et al.  Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage 2003;25 (2) 150- 168
PubMed Link to Article
Tolle  SWBascom  PBHickam  DHBenson  JAJ  Jr Communication between physicians and surviving spouses following patient deaths. J Gen Intern Med 1986;1 (5) 309- 314
PubMed Link to Article
Chau  NGZimmermann  CMa  CTaback  NKrzyzanowska  MK Bereavement practices of physicians in oncology and palliative care. Arch Intern Med 2009;169 (10) 963- 971
PubMed Link to Article
Curtis  JREngelberg  RAWenrich  MDShannon  SETreece  PDRubenfeld  GD Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 2005;171 (8) 844- 849
PubMed Link to Article
Curtis  JRPatrick  DLEngelberg  RANorris  KAsp  CByock  I A measure of the quality of dying and death: initial validation using after-death interviews with family members. J Pain Symptom Manage 2002;24 (1) 17- 31
PubMed Link to Article
Casarett  DPickard  ABailey  FA  et al.  A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life. J Palliat Med 2008;11 (1) 68- 75
PubMed Link to Article
Nelson  JEPuntillo  KAPronovost  PJ  et al.  In their own words: patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 2010;38 (3) 808- 818
PubMed Link to Article
Lynn  JTeno  JMPhillips  RS  et al. SUPPORT Investigators, Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 1997;126 (2) 97- 106
PubMed Link to Article
Hanson  LCHenderson  MMenon  M As individual as death itself: a focus group study of terminal care in nursing homes. J Palliat Med 2002;5 (1) 117- 125
PubMed Link to Article
Bakitas  MLyons  KDHegel  MT  et al.  Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302 (7) 741- 749
PubMed Link to Article
Hui  DElsayem  ADe la Cruz  M  et al.  Availability and integration of palliative care at US cancer centers. JAMA 2010;303 (11) 1054- 1061
PubMed Link to Article
Weissman  DE Consultation in palliative medicine. Arch Intern Med 1997;157 (7) 733- 737
PubMed Link to Article
Pantilat  SZRabow  MWCitko  Jvon Gunten  CFAuerbach  ADFerris  FD Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med 2006;166 (2) 227- 230
PubMed Link to Article
Gade  GVenohr  IConner  D  et al.  Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med 2008;11 (2) 180- 190
PubMed Link to Article
Norton  SAHogan  LAHolloway  RGTemkin-Greener  HBuckley  MJQuill  TE Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007;35 (6) 1530- 1535
PubMed Link to Article
Casarett  DPickard  ABailey  FA  et al.  Do palliative consultations improve patient outcomes? J Am Geriatr Soc 2008;56 (4) 593- 599
PubMed Link to Article
Grant  MElk  RFerrell  BMorrison  RSvon Gunten  CF Current status of palliative care—clinical implementation, education, and research. CA Cancer J Clin 2009;59 (5) 327- 335
PubMed Link to Article
Hui  DElsayem  ALi  ZDe La Cruz  MPalmer  JLBruera  E Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model. Cancer 2010;116 (8) 2036- 2043
PubMed Link to Article
von Gunten  CF Secondary and tertiary palliative care in US hospitals. JAMA 2002;287 (7) 875- 881
PubMed Link to Article
Rigby  AKrzyzanowska  MLe  LW  et al.  Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. Cancer 2008;113 (11) 3267- 3274
PubMed Link to Article
Smith  TJCoyne  PCassel  BPenberthy  LHopson  AHager  MA A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med 2003;6 (5) 699- 705
PubMed Link to Article
Casarett  DPickard  AAmos Bailey  F  et al.  Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage 2008;35 (2) 115- 125
PubMed Link to Article
Finlay  EShreve  SCasarett  D Nationwide Veterans Affairs quality measure for cancer: the family assessment of treatment at end of life. J Clin Oncol 2008;26 (23) 3838- 3844
PubMed Link to Article
Stone  M An asymptotic equivalence of choice of model by cross-validation and Akaike's criterion. J R Stat Soc Series B Stat Methodol 1977;3944- 47
Rabow  MWDibble  SLPantilat  SZMcPhee  SJ The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004;164 (1) 83- 91
PubMed Link to Article
Kuin  ACourtens  AMDeliens  L  et al.  Palliative care consultation in the Netherlands: a nationwide evaluation study. J Pain Symptom Manage 2004;27 (1) 53- 60
PubMed Link to Article
Manfredi  PLMorrison  RSMorris  JGoldhirsch  SLCarter  JMMeier  DE Palliative care consultations: how do they impact the care of hospitalized patients? J Pain Symptom Manage 2000;20 (3) 166- 173
PubMed Link to Article
Delgado-Guay  MOParsons  HALi  ZPalmer  LJBruera  E Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 2009;115 (2) 437- 445
PubMed Link to Article
Kellar  NMartinez  JFinis  NBolger  Avon Gunten  CF Characterization of an acute inpatient hospice palliative care unit in a U.S. teaching hospital. J Nurs Adm 1996;26 (3) 16- 20
PubMed Link to Article
Bascom  PB A hospital-based comfort care team: consultation for seriously ill and dying patients. Am J Hosp Palliat Care 1997;14 (2) 57- 60
PubMed Link to Article
Abrahm  JLCallahan  JRossetti  KPierre  L The impact of a hospice consultation team on the care of veterans with advanced cancer. J Pain Symptom Manage 1996;12 (1) 23- 31
PubMed Link to Article
 VA stats at a glance. National Center for Veterans Analysis and Statistics. 2010. US Dept of Veterans Affairs Web site. http://www.va.gov/vetdata/docs/QuickFacts/population_quickfacts.pdf. Accessed June 29, 2010

Figures

Tables

Table Graphic Jump LocationTable 2. Characteristics of Patients Receiving Usual Care, Care From a Palliative Care Consultation Team, and Care in a Palliative Care Unit
Table Graphic Jump LocationTable 3. Effect of Palliative Care Consultations and Palliative Care Units

References

Brazil  KHowell  DBedard  MKrueger  PHeidebrecht  C Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med 2005;19 (6) 492- 499
PubMed Link to Article
Fried  TRvan Doorn  CO’Leary  JRTinetti  MEDrickamer  MA Older persons' preferences for site of terminal care. Ann Intern Med 1999;131 (2) 109- 112
PubMed Link to Article
Higginson  IJSen-Gupta  GJA Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 2000;3 (3) 287- 300
PubMed Link to Article
Tang  ST When death is imminent: where terminally ill patients with cancer prefer to die and why. Cancer Nurs 2003;26 (3) 245- 251
PubMed Link to Article
 End of life care. Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18. Accessed June 28, 2010
 Facts on dying: policy relevant data on care at the end of life: USA and state statistics. http://www.chcr.brown.edu/dying/2001DATA.HTM. Accessed June 30, 2010
Brock  DBFoley  DJ Demography and epidemiology of dying in the U.S. with emphasis on deaths of older persons. Hosp J 1998;13 (1-2) 49- 60
PubMed Link to Article
Mitchell  SLTeno  JMKiely  DK  et al.  The clinical course of advanced dementia. N Engl J Med 2009;361 (16) 1529- 1538
PubMed Link to Article
Hanson  LCDanis  MGarrett  J What is wrong with end-of-life care? opinions of bereaved family members. J Am Geriatr Soc 1997;45 (11) 1339- 1344
PubMed
Teno  JMClarridge  BRCasey  V  et al.  Family perspectives on end-of-life care at the last place of care. JAMA 2004;291 (1) 88- 93
PubMed Link to Article
Wright  AAZhang  BRay  A  et al.  Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300 (14) 1665- 1673
PubMed Link to Article
Hofmann  JCWenger  NSDavis  RB  et al. SUPPORT Investigators, Patient preferences for communication with physicians about end-of-life decisions. Ann Intern Med 1997;127 (1) 1- 12
PubMed Link to Article
Curtis  JRPatrick  DLCaldwell  EGreenlee  HCollier  AC The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians. AIDS 1999;13 (9) 1123- 1131
PubMed Link to Article
McDonagh  JRElliott  TBEngelberg  RA  et al.  Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med 2004;32 (7) 1484- 1488
PubMed Link to Article
Higginson  IJFinlay  IGGoodwin  DM  et al.  Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage 2003;25 (2) 150- 168
PubMed Link to Article
Tolle  SWBascom  PBHickam  DHBenson  JAJ  Jr Communication between physicians and surviving spouses following patient deaths. J Gen Intern Med 1986;1 (5) 309- 314
PubMed Link to Article
Chau  NGZimmermann  CMa  CTaback  NKrzyzanowska  MK Bereavement practices of physicians in oncology and palliative care. Arch Intern Med 2009;169 (10) 963- 971
PubMed Link to Article
Curtis  JREngelberg  RAWenrich  MDShannon  SETreece  PDRubenfeld  GD Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 2005;171 (8) 844- 849
PubMed Link to Article
Curtis  JRPatrick  DLEngelberg  RANorris  KAsp  CByock  I A measure of the quality of dying and death: initial validation using after-death interviews with family members. J Pain Symptom Manage 2002;24 (1) 17- 31
PubMed Link to Article
Casarett  DPickard  ABailey  FA  et al.  A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life. J Palliat Med 2008;11 (1) 68- 75
PubMed Link to Article
Nelson  JEPuntillo  KAPronovost  PJ  et al.  In their own words: patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 2010;38 (3) 808- 818
PubMed Link to Article
Lynn  JTeno  JMPhillips  RS  et al. SUPPORT Investigators, Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 1997;126 (2) 97- 106
PubMed Link to Article
Hanson  LCHenderson  MMenon  M As individual as death itself: a focus group study of terminal care in nursing homes. J Palliat Med 2002;5 (1) 117- 125
PubMed Link to Article
Bakitas  MLyons  KDHegel  MT  et al.  Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302 (7) 741- 749
PubMed Link to Article
Hui  DElsayem  ADe la Cruz  M  et al.  Availability and integration of palliative care at US cancer centers. JAMA 2010;303 (11) 1054- 1061
PubMed Link to Article
Weissman  DE Consultation in palliative medicine. Arch Intern Med 1997;157 (7) 733- 737
PubMed Link to Article
Pantilat  SZRabow  MWCitko  Jvon Gunten  CFAuerbach  ADFerris  FD Evaluating the California Hospital Initiative in Palliative Services. Arch Intern Med 2006;166 (2) 227- 230
PubMed Link to Article
Gade  GVenohr  IConner  D  et al.  Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med 2008;11 (2) 180- 190
PubMed Link to Article
Norton  SAHogan  LAHolloway  RGTemkin-Greener  HBuckley  MJQuill  TE Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007;35 (6) 1530- 1535
PubMed Link to Article
Casarett  DPickard  ABailey  FA  et al.  Do palliative consultations improve patient outcomes? J Am Geriatr Soc 2008;56 (4) 593- 599
PubMed Link to Article
Grant  MElk  RFerrell  BMorrison  RSvon Gunten  CF Current status of palliative care—clinical implementation, education, and research. CA Cancer J Clin 2009;59 (5) 327- 335
PubMed Link to Article
Hui  DElsayem  ALi  ZDe La Cruz  MPalmer  JLBruera  E Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model. Cancer 2010;116 (8) 2036- 2043
PubMed Link to Article
von Gunten  CF Secondary and tertiary palliative care in US hospitals. JAMA 2002;287 (7) 875- 881
PubMed Link to Article
Rigby  AKrzyzanowska  MLe  LW  et al.  Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. Cancer 2008;113 (11) 3267- 3274
PubMed Link to Article
Smith  TJCoyne  PCassel  BPenberthy  LHopson  AHager  MA A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med 2003;6 (5) 699- 705
PubMed Link to Article
Casarett  DPickard  AAmos Bailey  F  et al.  Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage 2008;35 (2) 115- 125
PubMed Link to Article
Finlay  EShreve  SCasarett  D Nationwide Veterans Affairs quality measure for cancer: the family assessment of treatment at end of life. J Clin Oncol 2008;26 (23) 3838- 3844
PubMed Link to Article
Stone  M An asymptotic equivalence of choice of model by cross-validation and Akaike's criterion. J R Stat Soc Series B Stat Methodol 1977;3944- 47
Rabow  MWDibble  SLPantilat  SZMcPhee  SJ The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004;164 (1) 83- 91
PubMed Link to Article
Kuin  ACourtens  AMDeliens  L  et al.  Palliative care consultation in the Netherlands: a nationwide evaluation study. J Pain Symptom Manage 2004;27 (1) 53- 60
PubMed Link to Article
Manfredi  PLMorrison  RSMorris  JGoldhirsch  SLCarter  JMMeier  DE Palliative care consultations: how do they impact the care of hospitalized patients? J Pain Symptom Manage 2000;20 (3) 166- 173
PubMed Link to Article
Delgado-Guay  MOParsons  HALi  ZPalmer  LJBruera  E Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 2009;115 (2) 437- 445
PubMed Link to Article
Kellar  NMartinez  JFinis  NBolger  Avon Gunten  CF Characterization of an acute inpatient hospice palliative care unit in a U.S. teaching hospital. J Nurs Adm 1996;26 (3) 16- 20
PubMed Link to Article
Bascom  PB A hospital-based comfort care team: consultation for seriously ill and dying patients. Am J Hosp Palliat Care 1997;14 (2) 57- 60
PubMed Link to Article
Abrahm  JLCallahan  JRossetti  KPierre  L The impact of a hospice consultation team on the care of veterans with advanced cancer. J Pain Symptom Manage 1996;12 (1) 23- 31
PubMed Link to Article
 VA stats at a glance. National Center for Veterans Analysis and Statistics. 2010. US Dept of Veterans Affairs Web site. http://www.va.gov/vetdata/docs/QuickFacts/population_quickfacts.pdf. Accessed June 29, 2010

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 26

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
PubMed Articles
JAMAevidence.com

Care at the Close of Life EDUCATION GUIDES
Complexities in Prognostication in Advanced Cancer