Sourcebook : Improving Care for the End of Life : 3.1 Practices - Current, Better, Best

Nursing Home Resident Receiving Pain Medications, by Patient Age, Bernabei, et al., 1998. Most dying patients, in most settings, most of the time, are in pain or suffer other symptoms. In making baseline measures, many Breakthrough Series teams were surprised to find just how poorly their programs were doing - but this poor finding challenged groups to do better. The current state of pain management in most institutions in the country is far from ideal. In contrast, best practices enable clinicians to assess and alleviate most pain and other symptoms. When best practices are used, patients and families come to expect relief from suffering, not agony. By aiming for best and optimum practices, improvement teams can set goals for their patients, hospital wards or units, and institutions.

Practices in Managing Pain and Other Symptoms
Current Most often not assessed or monitored. Routinely receive inadequate treatment (e.g., drugs and dosages). Usually treated only after serious symptoms occurred, rather than as prevention. Gaps and delays in treatment are agonizing and commonplace. Major symptoms are presumed untreatable, though most can be relieved or reduced (pain, dyspnea, depression, anxiety, nausea, itching, insomnia, and so on). No one is held accountable for shortcomings. Patients and families expect severe symptoms and are grateful for any relief. Misinterpretation of patient’s behavior as meaning “no pain,” (e.g., sleeping, not writhing, etc.). Professionals and patients do not fully understand concepts such as addiction, tolerance, titration of doses, and management of opioid side effects. Regulatory barriers (i.e., triplicate prescribing laws) create patient fears and affect physician prescribing practices. Serious under treatment of neuropathic pain and lack of knowledge about adjuvant analgesics.	"Best" Pain and other symptoms assessed 100% of the time WHO/APS/AHCPR guidelines for cancer pain followed Low rate of orders for breakthrough pain--(repeated need for breakthrough symptoms triggers increased regular doses of pain medications) Rescue dose always available When pain is continuous, all opioids on regular dosing schedule Patients and families control timing of dosing for breakthrough pain Sufficient pain medication provided during medical procedures and transfers between units and facilities Severe symptoms (e.g., on a 0 to 10 scale, pain greater than 3 requires intervention, and greater than 6 is an emergency) receive emergency response Clinician performance routinely reviewed and shortcomings addressed Attend to and manage predictable side effects Educate patients and families about pain management	Better "Best" Assess pain, depression, dyspnea, and anxiety on specified schedule (admission, change in status, and periodically) 100% of the time Use all appropriate modalities, often on time-limited trials--including opioids, NSAIDS, adjuvant analgesics, physical therapy (apply heat and cold), massage therapy, behavioral techniques, hypnosis, steroids, neuroablative procedures, stimulants, and so on Respond to severe symptoms as an emergency Have skilled consultants readily available to patients in all settings (including ICU, hospital, nursing home, and home) Create settings in which patients and loved ones expect competence, control, and comfort During transfers between units or sites, never leave a patient in pain There are routine care reviews and feedback opportunities for quality improvement, public education, and accreditation.

The following case study shows how one organization pinpointed institutional barriers to effective pain management, then used Plan-Do-Study-Act cycles to improve practice.

3.1.1 Case Study - St. Mary's Health Center
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].