BACKGROUND: When a @entity1 is expected to die, the ideal plan of care focuses on comfort. Prior investigation of application of one institution's end-of-life symptom management order (ESMO) protocol suggested that comfort measures were often instituted too late and sometimes not at all. We studied @entity1 factors associated with missed opportunities for use of an ESMO protocol and protocol adherence in order to identify areas for quality improvement. METHODS: We abstracted the terminal hospitalization medical record for all adult decedents hospitalized for at least 3 days between April 2005 and April 2006 (n   =   496) at a university medical center. Detailed information was collected about ESMO use and opiate titration at the end of life. Among @entity1 expected to die, we used multivariate logistic regression to evaluate factors associated with whether @entity1 were placed on the ESMO protocol prior to @entity204 . RESULTS: Half of @entity1 who died received ESMO protocol care (n   =   248). All had documentation of a do-not-resuscitate (DNR) order (a requirement of the protocol). An opiate drip was used for 95% of @entity1 placed on the ESMO protocol and it was titrated up at least once for 67% of those @entity1 . @entity1 had a mean of 4 opiate titrations, but for only a mean of 2.2 was a justification documented (symptom documentation is required for each titration per the protocol). In a multivariable regression accounting for other demographic, clinical and provider variables, uninsured @entity1 (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.06-0.62), @entity1 admitted from a nursing home (RR 0.57, 95% CI 0.30-0.99), and @entity1 considered for transplant (RR 0.60, 95% CI 0.40-0.85) were significantly less likely to be placed on the ESMO protocol prior to @entity204 . CONCLUSIONS: Evaluation of implementation of a standardized order set can identify areas for quality improvement and missed opportunities for use.

Missed opportunities: use of an end-of-life symptom management order protocol among inpatients dying expected XXXX .

@entity1 :: ('9606', 'Species') :: ['patients', 'Patients', 'patient'] @entity204 :: ('MESH:D003643', 'Disease') :: ['death']
@entity204 :: (MESH:D003643,Disease) :: ['deaths']
