Beverly Williams | University of Phoenix (original) (raw)

Papers by Beverly Williams

Journal of women & aging, Jan 21, 2015

Using 2010 national data, we investigate the relationship between social integration and health i... more Using 2010 national data, we investigate the relationship between social integration and health insurance for African American adults. During the previous year 21.6% of men and 19.8% of women lacked continuous health insurance. The effect of marital status, income, and employment on insurance coverage differed by age and gender. Additionally, frequency of church attendance was positively associated with continuous health insurance for women aged 51-64. Spiritual/religious identity was marginally associated with insurance status for men aged 36-50. As provisions of the Affordable Care Act take effect, implementation programs should expand enrollment efforts to include the conjugal unit and the church.

Journal of social work in end-of-life & palliative care

This study explored next-of-kin's retrospective accounts of hospice and palliative care discu... more This study explored next-of-kin's retrospective accounts of hospice and palliative care discussions for hospitalized veterans. In-depth, face-to-face interviews were used to generate narrative accounts of 78 next-of-kin's experience of their loved one's hospital care during the last days of the patient's life. One-third of participants reported taking part in a hospice or palliative care discussion during the patient's final hospitalization. In over one-half of those cases, the patients died before discharge or transfer to hospice or palliative care was accomplished. Hospice and palliative care discussions in the hospital setting shaped family perceptions of the patients' care, directed family efforts in the days prior to death, and engendered anticipation of remaining quality time with the patient. Discussions about hospice or palliative care have meaning, emotional impact, practical effects, and unintended consequences for next-of-kin. Social workers in hos...

In fiscal year 2006, the US Government abruptly and drastically reduced its funding for programs ... more In fiscal year 2006, the US Government abruptly and drastically reduced its funding for programs to increase the racial and ethnic diversity of academic medicine, including programs to increase the development of minority medical faculty. Anticipating this reduction, 4 such programs-the Albert

Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 2008

This article describes the ingredients of successful programs for the development of minority fac... more This article describes the ingredients of successful programs for the development of minority faculty in academic medicine. Although stung by recent

The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2011

Early Childhood Research Quarterly, 1996

Death Studies, 2008

After-death research with next-of-kin can enhance our understanding of end-of-life care and trans... more After-death research with next-of-kin can enhance our understanding of end-of-life care and translate into better services for dying persons and their survivors. This article describes ethical and methodological issues that emerged in a pilot of a face-to-face interview guide designed to elicit next-of-kin's perceptions of end-of-life care. The pilot study was part of a larger Veterans Affairs (VA) Health Services Research protocol to improve end-of-life care in VA Medical Centers. By deconstructing the research process from an ethical perspective and engaging in critical self-assessment, the authors aim to inform other researchers of potential problems involved in after-death research with next-of-kin.

duration of effect; the implications of this will be discussed. Case description. When patients a... more duration of effect; the implications of this will be discussed. Case description. When patients are referred to a hospice with a life expectancy of days to short weeks the benefits of corticosteroids can easily outweigh the burden. However, as palliative medicine cares for patients with longer prognoses, such as months to years, more careful consideration of corticosteroid therapy is needed. Side effects of corticosteroids are numerous and dose-related. Dexamethasone is frequently the corticosteroid of choice; however, there are several other formulations that may be more appropriate depending on the clinical setting. This poster will present two illustrative case reports, review the basic pharmacology of corticosteroids, and summarize the limited case reports and RCTs related to corticosteroids in palliative care, and review common often avoidable side effects. The literature suggests that the benefit of corticosteroids for symptoms such as nausea may have a limited duration of effect; the implications of this will be discussed. Conclusion. Proposed guidelines for the use of corticosteroid formulations will be offered with dosing information, recommendations for prophylaxis, and weaning instructions. A convenient pocket card summarizing the discussion and recommendations will be provided for those visiting the poster.

The Journal of Men's Health & Gender, 2007

Background: Recent reports indicate that male breast cancer rates are increasing in North America... more Background: Recent reports indicate that male breast cancer rates are increasing in North America. While there have been numerous large-scale studies examining women's experiences with breast cancer, to date there have been no North American studies examining what a man experiences with a breast cancer diagnosis. The objective of this qualitative study was to describe the experiences of a sample of Canadian men diagnosed with breast cancer. Methods: After written informed consent, unstructured audio-taped interviews were conducted with 20 men. Since little is known about a man's experience with breast cancer, an exploratory qualitative approach was utilized. Results: Participants experienced concerns related to the lack of awareness of male breast cancer within both public and health professional groups. Many men suffered stress related to the cancer diagnosis, body image concerns and role strain. The lack of male-specific breast cancer information was identified as a major concern. All denied interest in traditional support groups. In retrospect, a number of men felt the breast cancer experience vastly improved their lives. Conclusions: Needs identified by participants include increased public and health professional awareness of male breast cancer, written information specific for men, and male participation in breast cancer research. Further study is also necessary to identify supports considered helpful by men with breast cancer and other malignancies.

The Journal of school nursing : the official publication of the National Association of School Nurses, 2004

Many pregnant adolescents remain in school, creating unique challenges for professionals to meet ... more Many pregnant adolescents remain in school, creating unique challenges for professionals to meet their educational and health needs. In this descriptive pilot study of pregnant adolescents (n = 26), 68% demonstrated symptoms of depression as measured by the Center for Epidemiologic Studies Depression Scale (CES-D). In addition, there was an expectation by the pregnant adolescent that postpartum social support received, as measured by the Postpartum Support Questionnaire, would be different from what is important to her. As an important part of the team, school nurses are uniquely positioned to screen pregnant adolescents for depression and to assist them in learning how to negotiate for the social support that is important to them.

Nurse education today, 2011

Competence is essential to ensuring safe, ethical and legal nursing practice. Various teaching st... more Competence is essential to ensuring safe, ethical and legal nursing practice. Various teaching strategies are used in nursing education in an effort to enhance graduate competence by bridging the gap between theory learned in the classroom and professional practice as a nurse. The objective of this comparative descriptive research was to determine if there was a difference in self reported competence between graduates from PBL and non PBL (NPBL) nursing programs. A convenience sample of 121 graduate nurses in one Canadian province, who had been practicing for at least 6 months took part in the study. The researcher designed questionnaire included both forced choice and open ended questions. There was no statistical significance difference between the PBL and NPBL graduates on self reported entry-to-practice competence. However, several significant themes did emerge from the answers to open ended questions which asked graduates how their nursing programs prepared them to meet the ent...

Gerontology & geriatrics education, 2014

A multicomponent, palliative care, education-based intervention was implemented in six Veterans A... more A multicomponent, palliative care, education-based intervention was implemented in six Veterans Affairs Medical Centers in the southeast United States. The intervention comprised onsite staff training plus supporting written materials, installation of an electronic order set, and follow-up consultations. Training included large-group didactic presentations, small-group clinical demonstrations, and one-on-one consultations. The intervention strategy was targeted broadly to hundreds of hospital providers, including physician, nursing, and ancillary staff. The purpose was to train staff in identifying actively dying patients and implementing best practices of home-based hospice care. A formative evaluation was conducted utilizing semistructured telephone interviews with key informants from each site. Qualitative data analysis revealed processes that facilitated or impeded uptake of the intervention. Results will be used to inform ongoing and future clinical initiatives and optimize fut...

The American journal of hospice & palliative care, Jan 29, 2014

End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed a... more End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed and occur earlier during hospitalization. This study explores the concept of sudden advanced illness (SAI) and its relevance to patients requiring Palliative and Surgical Critical Care. Semi-structured interviews were completed with 16 physicians, querying each about (1) definitional components, (2) illustrative cases, and (3) comfort with SAI. Analysis was done by grounded theory. SAI was characterized as unforeseen, emerging abruptly and producing devastating injury, often in healthy, younger patients. There is (1) prognostic uncertainty, (2) loss of capacity, and (3) unprepared surrogate decision-making. Cases are emotionally-charged and often personal. The emerging concept of SAI is important for understanding how Palliative Care can enhance care for this subset of patients.

Physiology & Behavior, 2001

Environmental enrichment has been shown to improve performance in tests of spatial memory, induce... more Environmental enrichment has been shown to improve performance in tests of spatial memory, induce neurogenesis in the hippocampus, enhance survival of newly formed granule cells, and inhibit spontaneous apoptosis. Although neuroplasticity of the mammalian brain declines with age, recent evidence suggests that the adult brain exhibits significant plasticity in response to environmental stimulation. The present study was designed to evaluate the effect of environmental enrichment on spatial memory and on immunoreactivity to cAMP response element binding protein (CREB) from the hippocampus. C57/BL/6 mice were trained in a Morris water maze after exposure to an enriched environment, either from 35 to 94 days or from 100 to 159 days of age. Hippocampal tissue from representative animals was later analyzed by Western blot for CREB immunoreactivity. Results indicate that environmental enrichment (particularly during the earlier period) improved performance on the Morris water maze and tended to increase immunoreactivity to CREB in the hippocampus. Social interaction by itself did not result in significant differences in navigational performance. Results with regard to social interaction and CREB immunoreactivity were mixed. Results are discussed in terms of evaluating the construct of enrichment, the correlation of CREB transcription and behavior change, and the importance of the developmental period for enrichment. D

Journal of Pain and Symptom Management, 2014

Journal of Pain and Symptom Management, 2013

All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Expl... more All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Explore next-of-kin's suggestions for improving end-of-life care in VA Medical Centers. 2. Discuss research, practice, and policy implications of next-of-kin's suggestions for improving end-of-life care in VA Medical Centers. 3. Suggest ways that next-of-kin suggestions can be translated into quality improvement initiatives in the clinical practice setting.

Journal of Pain and Symptom Management, 2012

Most patients with serious and life-limiting illness experience pain at some point in the illness... more Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory. To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life. Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005. Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P < 0.0001/0.0002), terminal condition (P < 0.0001/< 0.0001), family presence (P < 0.0001/0.0023), location of death (P = 0.003/0.0005), and having pain noted in the care plan (P = 0.0073/0.0007). Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.

Journal of Hospital Medicine, 2007

BACKGROUND: Low mobility is common during hospitalization and is associated with adverse outcomes... more BACKGROUND: Low mobility is common during hospitalization and is associated with adverse outcomes. Understanding barriers to the maintenance or improvement of mobility is important to the development of successful interventions.

Journal of General Internal Medicine, 2014

Widespread implementation of palliative care treatment plans could reduce suffering in the last d... more Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings. Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. Six Veterans Affairs Medical Centers (VAMCs). Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints. This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

Journal of women & aging, Jan 21, 2015

Using 2010 national data, we investigate the relationship between social integration and health i... more Using 2010 national data, we investigate the relationship between social integration and health insurance for African American adults. During the previous year 21.6% of men and 19.8% of women lacked continuous health insurance. The effect of marital status, income, and employment on insurance coverage differed by age and gender. Additionally, frequency of church attendance was positively associated with continuous health insurance for women aged 51-64. Spiritual/religious identity was marginally associated with insurance status for men aged 36-50. As provisions of the Affordable Care Act take effect, implementation programs should expand enrollment efforts to include the conjugal unit and the church.

Journal of social work in end-of-life & palliative care

This study explored next-of-kin's retrospective accounts of hospice and palliative care discu... more This study explored next-of-kin's retrospective accounts of hospice and palliative care discussions for hospitalized veterans. In-depth, face-to-face interviews were used to generate narrative accounts of 78 next-of-kin's experience of their loved one's hospital care during the last days of the patient's life. One-third of participants reported taking part in a hospice or palliative care discussion during the patient's final hospitalization. In over one-half of those cases, the patients died before discharge or transfer to hospice or palliative care was accomplished. Hospice and palliative care discussions in the hospital setting shaped family perceptions of the patients' care, directed family efforts in the days prior to death, and engendered anticipation of remaining quality time with the patient. Discussions about hospice or palliative care have meaning, emotional impact, practical effects, and unintended consequences for next-of-kin. Social workers in hos...

In fiscal year 2006, the US Government abruptly and drastically reduced its funding for programs ... more In fiscal year 2006, the US Government abruptly and drastically reduced its funding for programs to increase the racial and ethnic diversity of academic medicine, including programs to increase the development of minority medical faculty. Anticipating this reduction, 4 such programs-the Albert

Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 2008

This article describes the ingredients of successful programs for the development of minority fac... more This article describes the ingredients of successful programs for the development of minority faculty in academic medicine. Although stung by recent

The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2011

Early Childhood Research Quarterly, 1996

Death Studies, 2008

After-death research with next-of-kin can enhance our understanding of end-of-life care and trans... more After-death research with next-of-kin can enhance our understanding of end-of-life care and translate into better services for dying persons and their survivors. This article describes ethical and methodological issues that emerged in a pilot of a face-to-face interview guide designed to elicit next-of-kin's perceptions of end-of-life care. The pilot study was part of a larger Veterans Affairs (VA) Health Services Research protocol to improve end-of-life care in VA Medical Centers. By deconstructing the research process from an ethical perspective and engaging in critical self-assessment, the authors aim to inform other researchers of potential problems involved in after-death research with next-of-kin.

duration of effect; the implications of this will be discussed. Case description. When patients a... more duration of effect; the implications of this will be discussed. Case description. When patients are referred to a hospice with a life expectancy of days to short weeks the benefits of corticosteroids can easily outweigh the burden. However, as palliative medicine cares for patients with longer prognoses, such as months to years, more careful consideration of corticosteroid therapy is needed. Side effects of corticosteroids are numerous and dose-related. Dexamethasone is frequently the corticosteroid of choice; however, there are several other formulations that may be more appropriate depending on the clinical setting. This poster will present two illustrative case reports, review the basic pharmacology of corticosteroids, and summarize the limited case reports and RCTs related to corticosteroids in palliative care, and review common often avoidable side effects. The literature suggests that the benefit of corticosteroids for symptoms such as nausea may have a limited duration of effect; the implications of this will be discussed. Conclusion. Proposed guidelines for the use of corticosteroid formulations will be offered with dosing information, recommendations for prophylaxis, and weaning instructions. A convenient pocket card summarizing the discussion and recommendations will be provided for those visiting the poster.

The Journal of Men's Health & Gender, 2007

Background: Recent reports indicate that male breast cancer rates are increasing in North America... more Background: Recent reports indicate that male breast cancer rates are increasing in North America. While there have been numerous large-scale studies examining women's experiences with breast cancer, to date there have been no North American studies examining what a man experiences with a breast cancer diagnosis. The objective of this qualitative study was to describe the experiences of a sample of Canadian men diagnosed with breast cancer. Methods: After written informed consent, unstructured audio-taped interviews were conducted with 20 men. Since little is known about a man's experience with breast cancer, an exploratory qualitative approach was utilized. Results: Participants experienced concerns related to the lack of awareness of male breast cancer within both public and health professional groups. Many men suffered stress related to the cancer diagnosis, body image concerns and role strain. The lack of male-specific breast cancer information was identified as a major concern. All denied interest in traditional support groups. In retrospect, a number of men felt the breast cancer experience vastly improved their lives. Conclusions: Needs identified by participants include increased public and health professional awareness of male breast cancer, written information specific for men, and male participation in breast cancer research. Further study is also necessary to identify supports considered helpful by men with breast cancer and other malignancies.

The Journal of school nursing : the official publication of the National Association of School Nurses, 2004

Many pregnant adolescents remain in school, creating unique challenges for professionals to meet ... more Many pregnant adolescents remain in school, creating unique challenges for professionals to meet their educational and health needs. In this descriptive pilot study of pregnant adolescents (n = 26), 68% demonstrated symptoms of depression as measured by the Center for Epidemiologic Studies Depression Scale (CES-D). In addition, there was an expectation by the pregnant adolescent that postpartum social support received, as measured by the Postpartum Support Questionnaire, would be different from what is important to her. As an important part of the team, school nurses are uniquely positioned to screen pregnant adolescents for depression and to assist them in learning how to negotiate for the social support that is important to them.

Nurse education today, 2011

Competence is essential to ensuring safe, ethical and legal nursing practice. Various teaching st... more Competence is essential to ensuring safe, ethical and legal nursing practice. Various teaching strategies are used in nursing education in an effort to enhance graduate competence by bridging the gap between theory learned in the classroom and professional practice as a nurse. The objective of this comparative descriptive research was to determine if there was a difference in self reported competence between graduates from PBL and non PBL (NPBL) nursing programs. A convenience sample of 121 graduate nurses in one Canadian province, who had been practicing for at least 6 months took part in the study. The researcher designed questionnaire included both forced choice and open ended questions. There was no statistical significance difference between the PBL and NPBL graduates on self reported entry-to-practice competence. However, several significant themes did emerge from the answers to open ended questions which asked graduates how their nursing programs prepared them to meet the ent...

Gerontology & geriatrics education, 2014

A multicomponent, palliative care, education-based intervention was implemented in six Veterans A... more A multicomponent, palliative care, education-based intervention was implemented in six Veterans Affairs Medical Centers in the southeast United States. The intervention comprised onsite staff training plus supporting written materials, installation of an electronic order set, and follow-up consultations. Training included large-group didactic presentations, small-group clinical demonstrations, and one-on-one consultations. The intervention strategy was targeted broadly to hundreds of hospital providers, including physician, nursing, and ancillary staff. The purpose was to train staff in identifying actively dying patients and implementing best practices of home-based hospice care. A formative evaluation was conducted utilizing semistructured telephone interviews with key informants from each site. Qualitative data analysis revealed processes that facilitated or impeded uptake of the intervention. Results will be used to inform ongoing and future clinical initiatives and optimize fut...

The American journal of hospice & palliative care, Jan 29, 2014

End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed a... more End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed and occur earlier during hospitalization. This study explores the concept of sudden advanced illness (SAI) and its relevance to patients requiring Palliative and Surgical Critical Care. Semi-structured interviews were completed with 16 physicians, querying each about (1) definitional components, (2) illustrative cases, and (3) comfort with SAI. Analysis was done by grounded theory. SAI was characterized as unforeseen, emerging abruptly and producing devastating injury, often in healthy, younger patients. There is (1) prognostic uncertainty, (2) loss of capacity, and (3) unprepared surrogate decision-making. Cases are emotionally-charged and often personal. The emerging concept of SAI is important for understanding how Palliative Care can enhance care for this subset of patients.

Physiology & Behavior, 2001

Environmental enrichment has been shown to improve performance in tests of spatial memory, induce... more Environmental enrichment has been shown to improve performance in tests of spatial memory, induce neurogenesis in the hippocampus, enhance survival of newly formed granule cells, and inhibit spontaneous apoptosis. Although neuroplasticity of the mammalian brain declines with age, recent evidence suggests that the adult brain exhibits significant plasticity in response to environmental stimulation. The present study was designed to evaluate the effect of environmental enrichment on spatial memory and on immunoreactivity to cAMP response element binding protein (CREB) from the hippocampus. C57/BL/6 mice were trained in a Morris water maze after exposure to an enriched environment, either from 35 to 94 days or from 100 to 159 days of age. Hippocampal tissue from representative animals was later analyzed by Western blot for CREB immunoreactivity. Results indicate that environmental enrichment (particularly during the earlier period) improved performance on the Morris water maze and tended to increase immunoreactivity to CREB in the hippocampus. Social interaction by itself did not result in significant differences in navigational performance. Results with regard to social interaction and CREB immunoreactivity were mixed. Results are discussed in terms of evaluating the construct of enrichment, the correlation of CREB transcription and behavior change, and the importance of the developmental period for enrichment. D

Journal of Pain and Symptom Management, 2014

Journal of Pain and Symptom Management, 2013

All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Expl... more All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Explore next-of-kin's suggestions for improving end-of-life care in VA Medical Centers. 2. Discuss research, practice, and policy implications of next-of-kin's suggestions for improving end-of-life care in VA Medical Centers. 3. Suggest ways that next-of-kin suggestions can be translated into quality improvement initiatives in the clinical practice setting.

Journal of Pain and Symptom Management, 2012

Most patients with serious and life-limiting illness experience pain at some point in the illness... more Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory. To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life. Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005. Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P < 0.0001/0.0002), terminal condition (P < 0.0001/< 0.0001), family presence (P < 0.0001/0.0023), location of death (P = 0.003/0.0005), and having pain noted in the care plan (P = 0.0073/0.0007). Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.

Journal of Hospital Medicine, 2007

BACKGROUND: Low mobility is common during hospitalization and is associated with adverse outcomes... more BACKGROUND: Low mobility is common during hospitalization and is associated with adverse outcomes. Understanding barriers to the maintenance or improvement of mobility is important to the development of successful interventions.

Journal of General Internal Medicine, 2014

Widespread implementation of palliative care treatment plans could reduce suffering in the last d... more Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings. Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. Six Veterans Affairs Medical Centers (VAMCs). Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints. This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.