The one-page tool, known as the Care Plan Discussion Document (CPDD), was written and refined over the course of several months. On first glance, it is deceptively simple. According to Neil Wegner, M.D., a doctor could easily complete the form in four seconds. The discussions its designers hope to promote, however, can take much longer, by creating an opportunity for both patient and provider to discuss the goals and plan of treatment. Indeed, Wegner describes one provider who complained that the tool led him to spend several extra hours with a patient.
Katherine Brown-Saltzman, R.N., says that during its visit to UCLA Medical Center, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), praised the program.
The CPDD asks providers to note several aspects of the care being provided to a dying patient: Is the patient aware of his prognosis, for example, or is a DNR order in place. Originally, the form was intended only for doctors, but was modified to include material helpful for social workers assigned to patients. Social workers have found that their workload has increased as a result of asking patients to identify a surrogate decisionmaker; however, patient response to the project has been positive.
UCLA developed the CPPD after chart reviews led to grim findings: discussion of prognosis and the care plan came late in the course of treatment; a focus on prolonging survival compromised palliative care; DNR orders were written just before death; and hospice was not considered.
The tool aims to stimulate earlier discussions and provide a structured method to chart that conversations had occurred. The multiple-choice form addresses the following questions: What is the goal of admission? What is the chance of surviving one year? What does the patient think of this prognosis? Has the prognosis been discussed? What are the patient’s wishes for care? Which treatments would the patient undergo to prolong life?
The original intervention included 29 patients at different stages of end-stage diseases hospitalized on the medical unit. Of the 27 charts abstracted, 11 included a completed CPDD. In the control group, no patients had discussed prognosis or preferences; two had discussed resuscitation and had written DNR orders. Of the 11 charts with completed CPDD forms, seven patients had discussed their prognosis, four, their preferences; five, resuscitation; and five had completed DNR orders. All of the orders were completed within six days of admission.
Next steps include expanding the use of the document to the entire oncology unit and to gynecologic oncology. It is also being integrated into the medical management information system. The process has been integrated into service through head nurses, who identify end-of-life patients, and through QM chart reviews. The group intends to evaluate the program to assess its effects on end-of-life outcomes.
For more information, contact Katherine Brown-Saltzman, R.N., C.N.S., at UCLA Medical Center, LeConte Avenue, 14-176 CHS Department Nursing, Los Angeles, CA 90095, phone: 310.206.5734.
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