Randomized Trial of Care Management to Improve End of Life Care
Kenneth E. Rosenfeld MD
VA Greater Los Angeles Health Care System
West Los Angeles, CA
Funding Period: January 2004 - August 2008

BACKGROUND/RATIONALE:
Improving end-of-life care is of critical importance to the VA as it faces an increasingly aging and dying veteran population. In FY2000 approximately 104,000 enrolled veterans died in the U.S. including 27,200 that died as inpatients in VA acute or chronic care medical wards. Previous work within and outside of the VA has identified serious deficiencies in the quality of care delivered near the end of life. A pilot program of a collaborative care intervention in patients with advanced illness suggests that palliative care management may lead to improvements in processes and outcomes of care at reduced costs.

OBJECTIVE(S):
The purpose of this project is to test the effectiveness of a chronic illness model-based palliative care intervention that utilizes prognosis-based palliative care evaluation and longitudinal nurse care management on the processes and outcomes of end-of-life care at one VA medical center.

METHODS:
The study uses a randomized, controlled design. All patients admitted to the inpatient medical service during the enrollment period are screened for survival prognosis by their admitting resident physician. Patients estimated to have at least a 25% risk of dying over the following year and who meet other basic inclusion criteria are invited to participate. Consenting patients are randomized to intervention or usual care. The intervention entails initial palliative evaluation followed by nurse care management designed to promote informed goal-setting, symptom management, psycho/socio/spiritual support, and family support. Data collection activities include patient and caregiver surveys, chart reviews, and reviews of administrative databases. Primary study outcomes include caregiver-rated quality of death and dying, hospital-based resource use, and costs; secondary outcomes include patient quality of life, satisfaction with care, continuity and coordination of care, and patient self-determination

FINDINGS/RESULTS:
Cross-sectional analysis of the first 220 patient baseline interviews suggests that veterans with both cancer and non-cancer conditions have a high prevalence of symptoms, functional impairment, depression, and unmet support needs. Provider communication of prognosis, though often lacking, is strongly associated with patient understanding of the life-limiting nature of their illness. Patients with non-cancer diagnoses are less likely to perceive themselves as living with life-limiting illness but are more likely to recognize that their illness cannot be cured. While African Americans were found to be less likely to discuss and document care preferences, discussion of care preferences was found to be lacking for patients in all demographic groups. Lastly, patients' understanding of life-limiting illness is predictive of patient discussion of treatment preferences with providers and families.

Interim analysis of the first 197 patients who died has begun. Preliminary analysis suggests that control patients had more days in the ICU during the last 30 days of life, intervention patients had fewer ER visits resulting in hospitalization, and intervention patients had fewer hospital days during the last 30 days of life.

IMPACT:
If shown to be effective, the palliative care program tested in this study will be the first of its type to demonstrate success in a controlled trial, and it will be ready for larger-scale implementation studies that will inform models of end-of-life care delivery both within and outside of the VA. Administrators at VAs nationwide, including chiefs of service, chiefs of staff, hospital directors, and VISN directors will be able to use the plans and protocols developed in this project to develop programs at their own institutions. Nurses, generalist physicians, and specialists can gain important insights about the special needs of seriously ill patients and the role of care systems in delivering high-quality end of life care. Finally, the project has immediate relevance to the healthcare system at large, as it struggles to find effective end-of-life care delivery models.


PUBLICATIONS:

Journal Articles

1. Fromme EK, Hughes MT, Brokaw FC, Rosenfeld KE, Arnold RM. Update in palliative medicine 2008. Journal of Palliative Medicine. 2008; 11(5): 769-75.
2. Lorenz KA, Rosenfeld K, Wenger N. Quality indicators for palliative and end-of-life care in vulnerable elders. Journal of The American Geriatrics Society. 2007; 55 Suppl 2: S318-26.
3. Chang VT, Sorger B, Rosenfeld KE, Lorenz KA, Bailey AF, Bui T, Weinberger L, Montagnini M. Pain and palliative medicine. Journal of Rehabilitation Research and Development. 2007; 44(2): 279-94.
4. Krouse RS, Mohler MJ, Wendel CS, Grant M, Baldwin CM, Rawl SM, McCorkle R, Rosenfeld KE, Ko CY, Schmidt CM, Coons SJ. The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample. Current Medical Research and Opinion. 2006; 22(4): 781-91.

DRA: Aging and Age-Related Changes, Chronic Diseases, Health Services and Systems
DRE: Quality of Care
Keywords: Advance directives, End-of-life, Managed care
MeSH Terms: none