In-hospital deaths are a fact of life, but officials at 360-bed Daniel Freeman Memorial Hospital in Inglewood, Calif., worried about what could have been every time a patient passed away.
Now the hospital has a system in place designed to improve the way patients with terminal illnesses are treated.
"There wasn't a formalized support system for patients dealing with end-of-life issues and no way for us to trigger a formal support system," says Donna Miller, Daniel Freeman's coordinator for clinical pathway development.
So-called "good deaths"--those that occurred pain-free, with a patient's family at the bedside--were being recorded less than a quarter of the time. Many patients were receiving futile measures, such as intensive laboratory tests and resuscitations.
"Most people are less afraid of dying than how they die . . . if it's a traumatic death, it's hard on the family and hard on the staff," Miller says. Such in-hospital deaths also appeared to be inconsistent with Daniel Freeman's religious tenets about preserving dignity at the end of life. The hospital is part of St. Louis-based Carondelet Health System, which operates 14 hospitals in seven states.
In late 1997, officials and physicians from a dozen departments met to discuss ways to revamp the ways terminally ill patients were handled. Forty-two deaths of terminally ill patients at the hospital in the first quarter of 1997 also were examined to establish a baseline for the hospital's practice patterns.
In mid-1998, with the help of Daniel Freeman's pastoral-care program, the hospital's comfort-care project was introduced. Emphasis was shifted from aggressively treating a terminal condition to providing care and medication that would make patients as comfortable and pain-free as possible. Staff was retrained to be more sensitive to the needs of patients and their families.
Perhaps most important, four hospital volunteers were trained either by hospice organizations or the American Cancer Society to interact with families and help when they're faced with the difficult decision to switch from aggressive treatment to comfort care. "Sometimes people are more comfortable not asking questions of those who are direct health providers," Miller says.
The specially trained volunteers have proved invaluable when it comes to smoothing the frayed nerves of both patients and their families, according to Bonnie Rohrbaugh, Daniel Freeman's director of volunteer services. "Sometimes just assuring (patients) that we're supporting their families is a benefit," she says.
But volunteers often do more than that. "In some cases, they stay with a patient, so the family member can feel free to go home and change clothes or fix a meal or get some rest. Sometimes it involves going to the cafeteria and getting them some food. Sometimes it just involves sitting with a person and listening to them talk about their loved ones, or having them bounce off of you the difficult choices they need to make," Rohrbaugh says. Volunteer involvement with a patient's family can often average several hours per week, she adds.
The comfort-care program has made a big difference. In the year after its implementation, the number of terminally ill patients requesting no heroic intervention more than doubled to 50% from 24%. The use of mechanical ventilators, blood transfusions and duplicative lab tests was reduced anywhere from a third to nearly 70%. And "good deaths" were recorded 40% of the time, up from 23% before the program was started.
Costs for implementing the program weren't calculated, but hospital officials say it's probably cut down on the use of expensive interventions and resuscitations.
In-house educational sessions are helping to keep the program fresh and vibrant. Plans also are being discussed for expanding the program to 179-bed Daniel Freeman Marina Hospital in nearby Los Angeles.
"It's very rewarding work. You know that you've provided people the time that medical people can't always give," Rohrbaugh says.