Evidence-Based Practice

in End of Life Care

By: Kyra Barstad, Julia Binder, Chloe Dewitt, Angelica Painter, Bella Rahal, Daniel
Reavis, Haley Small, Kayla Sonderman, Lindsay Weigel

Lab Group A
Introduction
● What is End of Life care?
○ Hospice Care vs. Palliative Care
● In what setting does End of Life care occur?
○ Home, hospice, nursing home, hospital
● When do people receive it?
○ Transition away from traditional hospital ● Significance to Nursing
curative care. Focus on comfort and holistic ○ Role of nurses in palliative and end of life care
needs of patient ■ Advocacy and Communication
● Who is involved in care? ■ Nurses know the patient!
○ Multi-disciplinary team
(National Institute of Health, 2017) (Hagan, Xu, Lopez, & Bressler, 2018)
PICOT Question

In patients receiving end-of-life care what is

the effect of home-based hospice care
compared to inpatient hospice care on
patient and family satisfaction?
Summary of Current Practice

National
● End-of-life care established within the Medicare Hospice Benefit
○ Hospice certification: must include medical, nursing, social work, chaplaincy, and
bereavement support
● 41% of hospice care patients receive care at home, 22% inpatient hospice
● Growth of hospital palliative care teams
(Morrison, 2015)
Summary of Current Practice
State
● Palliative care teams in hospitals
● Adheres to National guidelines established in Hospice Medicare Benefit
○ Additional state requirements - such as licensure through Joint Commission
(Morrison, 2015)
Local (St. Joseph’s Hospital)
● No specific palliative care team, but physicians and case managers guide patients and families through
available options
● No specific training for nurses
● Focus of care changes to comfort measures and controlling pain
● Nurses act as resources for the patient and family
Synopsis of Research
● Main findings:
○ No matter the setting, patient-family satisfaction determined to be equal
○ Four main variables:
■ Information about patient, consistency, spiritual care, and anxiety reduction
○ Earlier intervention associated with
■ greater satisfaction
■ decreased cost to patient and hospital
○ Nurse education associated with greater confidence and patient satisfaction
● Levels of evidence from III-VI
○ Cross-sectional studies, cohort studies, quasi-experimental studies
Strengths and Limitations of Research
Strengths
● Peer reviewed
● Complementary & refined
● Easy to analyze

Limitations
● Sample size
● Findings may not be reproduced
● Data collection
Evidence Based Recommendations
Research findings:
● Hospice patients and their families were equally satisfied in both home
hospice and inpatient hospice settings
○ Factors that cause increased patient and family satisfaction:
■ Patient information
■ Consistency in care
■ Spiritual care
■ Anxiety reduction

Integration with Guidelines for Best Practice:

● National guidelines for hospice patient care should align with factors that
increase patient/family satisfaction in research
Guidelines for Best Practice
● Assess
○ Contributing diagnoses, medical history
○ Psychiatric state, social support, familial support, spiritual and cultural values,
and financial need
● Advocate
○ On behalf of assessed needs, values, goals, and expectations
● Educate
○ Continuing nursing education to meet standard of care
○ Patient and family member referrals
● Collaborate
○ Involve all members of healthcare team
● Intervene
○ Symptom management as ordered, therapeutic communication

(National Consensus Project for Quality Palliative Care, 2018)

Integration of Evidence and Best
Practice
● Research:
○ Setting in which patients receive hospice care did not have a clear statistical difference in patient
or family satisfaction
○ Factors that do improve patient satisfaction support current best practice hospice nursing care
● Integration:
○ Adherence to hospice care protocol after patient hospice referral yields the most satisfaction.
 Overall Application and
Implementation to Nursing
● Policy development - January 10, 2020
○ Palliative care team works with ICU nursing management to create a policy
○ Policy development meetings will occur once a week through February 10,
2020
● Nursing education - February 10, 2020
○ Mandatory training for ICU nurses will be available for two weeks
○ Training will begin February 10 and last through February 28
○ Nurses are required to attend 15 hours of online training modules during
this time
● Implementation to nursing practice - March 1, 2020
○ Nurses will implement the knowledge they gained through nursing
education on caring for patients in hospice care

(National Consensus Project for Quality Palliative Care, 2018)

 (Hasbro Monopoly Money, 2019)

Cost Analysis: Implementation

Training Cost Application of cost at St. Joseph’s

● Online Course Training (OCT): ● Number of ICU nurses:

○ $199 Per person ○ +/- 42 x $199
■ +/- $8,358
 (VR-Training, 2019)

Cost Analysis: Comparison

Hospital Cost Cost Findings
● Training all NICU nurses using LDT
● Virtual Reality Training (VRT): would cost $76,650.02 for the first
○ $ 327.78 per person year.
○ LDT has a constant re-training
○ $106,951.14 Total
price.
■ 57 employees ● Training all U nurses using VRT would
cost $109,747.97 for the first year
● Live Drill Training (LDT): ○ VR re-training cost $3090.97
○ $229.75 per person
○ $18,617.54 Total
■ 57 employes (May, Et al., 2015)
Cost Analysis: Patient Savings
Patient Savings Decreased Hospital Cost
● Late education and Intervention (compared to no intervention)
○ stayed in the hospital an average
of 9.5 days ● Intervention within six days
○ variable direct cost of $17,444 per ○ $1,312 per patient
case. ● Intervention two days
● Early Education and Intervention
○ stayed in the hospital less than ○ $2,280 per patient
two days ● Cost saving implied is 14% of total
○ direct cost variable of $1,017 per direct hospital costs for a consult
case. within 6 day and 24% within two
● Difference in cost days!
○ $16,427
(Fermia, & Et al., 2016) (May, Et al., 2015)
Cost Analysis: Importance of
Implementation
● Long term hospital cost savings
● Patient cost savings
● Increased patient satisfaction

(Sullender Et al., 2016)

(Win-Win, 2014)
 Risk vs. Benefit Based on Research: Home-Based
Hospice Care
● Risk of home-based hospice:
○ Advanced level of care is needed (Ong, Brennsteiner, Chow, & Hebert, 2016).

● Benefit of home-based hospice:

○ The patient has the ability to die at home (Bainbridge & Seow, 2018).
○ Decreased cost burden (Chiang & Kao, 2016).
○ Spiritual & cultural needs were met fully (Unroe, Stump, Effler, Tu & Callahan,
2018).
Risk vs. Benefit Based on Research: Inpatient
Hospice Care
● Risk of inpatient hospice:
○ Increased cost related to time spent in the hospital (Fermia, Wilkins, Rodriguez,
Read, Gavin, & Caspers, 2016).
○ Less likely to report receiving excellent care compared to those receiving care at
home (Unroe, Stump, Effler, Tu, & Callahan, 2018).
○ Less likely to feel the death of the patient occured in a setting of their choice (Unroe,
Stump, Effler, Tu, & Callahan, 2018).
○ Increased burden on family (Chiang & Kao, 2016).
● Benefit of inpatient hospice:
○ Family feels everything is being done to keep their loved one comfortable (Fermia,
Wilkins, Rodriguez, Read, Gavin, & Caspers, 2016).
Evaluation: SMART Outcomes
Hospital
The hospital will implement a comprehensive hospice education module into annual
education/training for all ICU nurses by February 28th, 2020.
Nursing Staff
All ICU nurses will report understanding their role during the transition to hospice care and
feeling confident in their ability to perform these duties upon completion of the training module.
Patients/Families
Patient and family satisfaction with end of life care will increase after staff receives the hospice
training as evidenced by higher satisfaction scores on discharge surveys.
Summary
● Introduction
● Description of issue
● Supportive studies
● Best practice
● Application to facility
● Cost analysis
● Risk vs. benefit
Summary

PICOT: In patients receiving end-of-life care what is the effect of home-based

hospice care compared to inpatient hospice care on patient and family satisfaction?

As a group and based on research we feel confident in stating that patient and family
satisfaction is consistent throughout home-based hospice and inpatient hospice
care. However, with the implementation of this intervention, satisfaction rates will
continue to improve in the future.
Questions???
Thank you!
References
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Chiang, J. K., & Kao, Y. H. (2016). Impact of home hospice care on patients with advanced lung cancer: A longitudinal population-based study in

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10.1097/CIN.0000000000000540
References
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