Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : 8.2 Building a Model That Works : 8.2.3 Case Study - Detroit Receiving Hospital

In 1986, Detroit Receiving Hospital, a Level 1 Trauma Hospital, established the Comprehensive Supportive Care Team, designed as a nurse-directed collaborative practice between a physician and an advanced practice nurse to provide comprehensive, comfort-focused care to dying patients and their families. Services are offered after a transfer of service from the admitting physician/resident team, or in consultation with the primary team. The supportive care team provides clinical ethics consultation related to end-of-life issues, teaches staff and students, and conducts clinical research.

The primary medical or surgical physician/resident team refers patients who are not expected to survive hospitalization. The team evaluates each patient and independently determines whether or not they can be of help to the patient. If so, the team accepts the patient and develops a comprehensive therapeutic plan that addresses patient and family wishes regarding life-sustaining measures, comfort, and psychological and spiritual needs.

The advanced practice nurse and physician round together daily and evaluate and revise the therapeutic plan as needed. The advanced practice nurse has institutional prescriptive privileges that permit her to serve as the primary provider responsible for each patient.

Patients referred to Supportive Care from the ICU are moved to a special area of dedicated beds where the therapeutic plan is implemented. This process provides a triage option for the ICU and privacy and unrestricted visiting for the dying patient and his or her loved ones. The patient remains with the Comprehensive Supportive Care Team until death or discharge, unless a change in condition warrants a return to the referring service for more vigorous treatment.

Figures 8.1, 8.2, and 8.3 reflect a few facts about the service, including trends in referrals and in the average length of stay, which has gone from 13 days in 1986 to 4 days in 1997. Hospital charges are reduced dramatically when patients are cared for by the Supportive Care Team. Traditional care for 31 anoxic encephalopathy patients averaged about $35,000; Supportive Services provided care for 31 similar patients at a cost of about $12,000.

Referral Sources to Supportive Care Team, Detroit Receiving Hospital, Detroit, MI. Average Length of Stay, Detroit Receiving Hospital, Detroit, MI. Charges for Encephalopathy Patients, Detroit Receiving Hospital, Detroit, MI.

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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 ].

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