Sourcebook : Improving Care for the End of Life : 3.5 Use Culturally Appropriate Pain Assessment Methods

San Francisco's On Lok Senior Health Services, the original model for the Program for All-Inclusive Care of the Elderly (PACE), serves a culturally and ethnically diverse patient population of frail elders. When its Breakthrough Series team found that standard pain scales did not work well for its patients, the team developed its own tools, including an assessment that gauged the patient's emotional state, nonverbal cues, and mobility. The questionnaire asked patients about their desire for comfort, their current status, and their goals for the future.

Goals for patients nearing the end of life included:

• Instituting a "Comfort Care" program at least 28 days before death
• Providing pain assessment and management to 100 percent of patients
• Offering psychosocial and spiritual support to 80 percent of patients
• Having 90 percent of patients' families participate in a family conference

To measure improvement, On Lok staff followed progress notes in medical records:

• Reviewing all deaths each month
• Identifying deaths caused by chronic illness
• Documenting the date the comfort care plan was begun
• Looking for evidence of pain management, psychosocial and spiritual support, and counseling

Because the average On Lok participant is in the program for three years, staff often found it difficult to acknowledge when a patient was nearing the end of his or her life. To help interdisciplinary staff recognize this phase of life, the On Lok team offered training sessions that included a focus on observing changes in patients (such as decreased or difficult mobility, slow or guarded behavior, and withdrawal from usual interactions).

The accompanying chart demonstrates On Lok's success: Within months of starting this project, the percentage of patients with pain intensities greater than 4 decreased from 60 percent to 20 percent. Within one year, pain assessment and management for dying patients went from 33 percent to 86 percent of patients, and the length of comfort care plans increased from 13.6 days at the start of the project to 54.9 by its conclusion.

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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 ].