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Improving End-of-Life Care in the Hospital

Investigators: Nancy Berlinger, The Hastings Center; Howard Epstein, Society of Hospital Medicine
Funder: The Milbank Foundation

Hospitalists – physicians specializing in the general medical care of hospitalized patients – and other frontline clinicians with whom they work are de facto providers of end-of-life care in the hospital. And yet they have not been provided with training in the crucial skills needed to plan care and support patients and families when patients are nearing the end of life. The Hastings Center and the Society of Hospital Medicine (SHM), the largest medical society representing hospitalists, will create new skills-based training resources for hospital clinicians and a quality improvement framework for hospital leaders.

The project responds directly to national calls to improve the care American receive as they approach the end of life. The Joint Commission, the major accreditation and certification body for hospitals and other health care organizations, has explicitly identified end-of-life care as a patient safety issue due to the medical and nursing interventions that a seriously ill, hospitalized patient is likely to experience. The Center for Medicare and Medicaid Services will reimburse physicians and other qualified professionals for conducting voluntary advance care planning with Medicare patients starting on January 1, 2016. The Medicare reform means that a much wider range of professionals need basic training in how to discuss end-of-life care preferences, review and update care plans, and support surrogate decision-makers. The Hastings Center-SHM collaboration will create the organizational framework that the Joint Commission recommends, and also training resources tailored for frontline clinicians.

The project has two major aims:

1) to build institutional support among hospital leaders to acknowledge and strengthen the role of hospital clinicians in improving EOL care in the hospital, and

2) to build the skills of hospital clinicians as effective providers of primary palliative care [i] for patients nearing the EOL, drawing on the content of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life(Oxford University Press, 2013) and the SHM’s proven method of online education.

Goals and Impact

In July 2015, The Hastings Center and the SHM convened an interdisciplinary meeting of national stakeholders, including working hospital clinicians, patient and family advocates, representatives from the American Association for Critical-Care Nurses, and other experts, to discuss the specific challenges of providing end-of-life care to patients and families whom clinicians are meeting for the first time under stressful conditions.

With insights from this meeting, The Hastings Center and SHM will build a virtual Resource Room on Improving End-of-Life Care in the Hospital for the SHM’s publically accessible website. The content for this web-based training curriculum and toolkit will be developed by the co-directors and an SHM Expert Panel of clinician-educators practicing in hospital and palliative medicine. Specific resources to be launched in 2016 will include:

1) A quick-reference tool for hospital clinicians based onThe Hastings Center Guidelines, with step-by-step guidance on ACP, decision-making, and care transitions in the hospital context.

2) CME modules, slide sets for clinician education, and communication tools as structured resources for use by hospital clinicians amid their workplace realities.

3) A quality improvement (QI) framework for using these practical and educational tools to make organizational EOL care systems safer and more responsive to patients and families.

4) A case statement addressed to hospital clinicians as professionals and mentors in efforts to improve EOL care, and for outreach to hospital leadership responsible for investing in EOL care systems and supporting frontline clinicians.