Intervention to Improve Care at Life's End

Study Overview
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Brief Summary
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The BEACON trial (Best Practices for End-of-Life Care for Our Nations' Veterans) was a six-site implementation study to evaluate a multi-component, education-based intervention to improve the quality of end-of-life care provided in VA Medical Centers.

Detailed Description
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The BEACON trial (Best Practices for End-of-Life Care for Our Nations' Veterans) was a six-site, real-world implementation trial of a multi-component, education-based intervention to improve the quality of end-of-life care conducted in VA Medical Centers (VAMCs). The primary aim was to evaluate the effectiveness of a multi-component intervention for improving processes of care provided in the last days of life in VAMCs. The second aim was to conduct after-death interviews with next-of-kin and qualitative analysis of their perceptions of the care provided to the veteran and family. The multi-component intervention targeted VAMC inpatient providers, including physician, nursing, and ancillary staff. It consisted of preparatory site visits, a staff training program, a newly developed Comfort Care order set decision support tool built into the CPRS, and follow-up consultation. The intervention team travelled to each site to conduct two weeks of comprehensive in-service training. Staff were trained to identify actively-dying patients and implement a set of best practices of traditionally home-based hospice care for dying patients. The team provided assistance with policies, procedures, and skill training needed to implement comfort care interventions. Introduction of the intervention at each VAMC was staggered across time at six-month intervals using a multiple-baseline, stepped wedge design. Data on processes of end-of-life care (last 7 days) were abstracted from the CPRS medical records of all veterans who died before, during, and after the intervention (January 2005-February 2011). A priori, five processes of care were identified as primary endpoints to indicate quality of end-of-life care: 1) presence of an order for opioid pain medication at time of death; 2) a do-not-resuscitate (DNR) order in place at time of death; 3) location of death; 4) presence of enteral feeding tube or intravenous line at time of death; and 5) physical restraints in place at or near time of death. In addition, in-depth, face-to-face interviews were conducted with 78 bereaved next-of-kin.

Official Title
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Intervention to Improve Care at Life's End in VA Medical Centers

Conditions
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Death, Pain, Dyspnea

Intervention / Treatment
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* Behavioral: Comfort care education intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aim 1: Not applicable. Patients were deceased. Aim 2: After-death interviews with next of kin: must be willing and able to participate in after-death interview at local VA Medical Center. Exclusion Criteria: N/A
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm 1<br>Comfort care education intervention, consisting of intensive, on-site staff training together with an electronic order set for palliative care and educational materials | Behavioral: Comfort care education intervention<br>* Comfort care education intervention, consisting of intensive, on-site staff training together with an electronic order set for palliative care and educational materials<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Presence of Order for Opioid Pain Medication | Presence of order for opioid pain medication at time of death based on abstraction of electronic medical record | Pre and Post Intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Do Not Resuscitate Order | Presence of a Do Not Resuscitate order at time of death based on abstraction of electronic medical record | Pre and Post Intervention | 
| Number of Patients Who Died in ICU | Location of death (ICU vs. other) based on abstraction of electronic medical record | Pre and Post Intervention | 
| Individuals With a Nasogastric Tube | Presence of nasogastric tube based on abstraction of electronic medical record | Pre and Post Intervention | 
| Individuals With an Intravenous Line | Presence of intravenous line infusing at time of death based on abstraction of electronic medical record | Pre and Post Intervention | 
| Number of Individuals Who Died in Restraints | Presence of restraints at or near time of death at time of death based on abstraction of electronic medical record | Pre and Post Intervention | 
| Individuals Administered of Opioid Medication | Administration of opioid medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals With an Order for Antipsychotic Medication | Order for antipsychotic medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals Administered Antipsychotic Medication | Administration of antipsychotic medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals With an Order for Benzodiazepine Medication | Order for benzodiazepine medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals Who Received Benzodiazepine Medication | Administration of benzodiazepine medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals Who Received Scopolamine | Administration of scopolamine (for death rattle) based on abstraction of medical record | Pre and Post Intervention | 
| Sublingual Administration | Sublingual administration of medication based on abstraction of medical record | Pre and Post Intervention | 
| Individuals With Pastoral Care Visit | Pastoral Care Visit based on abstraction of medical record | Pre and Post Intervention | 
| Individuals With an Advance Directive | Presence of advance directive based on abstraction of medical record | Pre and Post Intervention | 
| Individuals With a Palliative Care Consultation | Palliative Care Consultation based on abstraction of medical record | Pre and Post Intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Quality of Health Care, Inpatients, Professional education, Palliative Care, Terminal Care, Hospice Care, Patient Care Planning, Nursing Care Plans, Resuscitation orders, Pastoral Care