Integrated Approach to Palliative Care in Acute Care (iPAC-AC)

Rationale: There is a gap between research knowledge and point-of care practice, but bridging this gap is a complex, value laden process. This project responds directly to needs identified by practitioners, and addresses the imperative of integrating a palliative approach in acute care.

Hypothesis: Participatory approaches to knowledge translation (KT) can increase the integration of a palliative approach into acute care medical units.

Objectives: In this project we will use participatory approaches to test the feasibility of integrating a palliative approach into acute care medical units. That is, we will facilitate the translation of research findings into point-of-care practice, with the ultimate goal of enhancing care. This project will combine inquiry and action to support the integration of a palliative approach.

Research plan: Building on our previous research, we will use participatory approaches with multidisciplinary care teams on acute care units to integrate a palliative approach into practice. Our project involves three main activities: (a) initial data collection, (b) frequent engagement with care teams and (c) evaluation. We will engage with care teams to: (1) explore beliefs, assumptions and practices around care for older adults with life-limiting illness, (2) share information about a palliative approach and its potential benefits, (3) develop strategies to integrate a palliative approach into their work, (4) evaluate these strategies and their influence on patient and family outcomes and (5) analyze how the Knowledge-As-Action framework, which was specifically developed to facilitate practice-oriented collaboration for KT, can guide the integration of a palliative approach.

Key Findings

• When patients and families talk openly about end-of-life it can improve their quality of life
• Health care staff benefit from on-the-job education on how to talk about end-of-life with patients and families
• There are positive benefits to shifting care from task-focused to patient-centred

Evidence gap addressed by study/Why this study was needed

Most people in Canada want to die at home; however, a great majority die in hospital. Up to 35% of patients in hospital could benefit from end-of-life care but are not getting it. Hospice care is not appropriate for everyone. This study looked at how we can adjust communication between patients, families, and health care staff in order to improve the last 12 months of life.

Suggestions on how these findings could impact older adults living with frailty and/or their family caregivers and how this might be measured

• Health care staff, patients, and families talking about illness and care wishes can improve the type and quality of care provided to patients
• Staff need support and help to have open conversations about goals of care

Study Summary

• This study took place on one hospital unit.
• Health care staff were taught how to recognize patients with life-limiting illness.
• Over 6 months, staff made improvements in their comfort in talking with patients and families about end-of-life care.
• For change to last, the health care team needs to be ‘on the same page’ and have the support of hospital leadership.

Key Findings

• Integration of a palliative approach can lead to better identification of those at risk of dying, perceived improvements in provider-patient communication, and promote the care team to “get on the same page” to promote quality care.
• There are positive benefits for providers including a shift from a task orientation toward a palliative approach to care, and the fostering of individual agency, confidence and commitment to change practice and improve care for the dying.
• The action research shows promising practices for identification of palliative patients and better-informed decision making by health care providers, families, and patients in terms of interventions for patients with chronic life-limiting conditions.

Evidence gap addressed by study/Why this study was needed

Despite evidence that most people prefer to die at home, acute care functions as the major provider of end-of-life care with research suggesting up to 35% of all hospital inpatients have palliative care needs. We require improvements to care that promote the best outcomes for patients, families, and the healthcare system. For decision-makers this challenge is here and growing; these patients fill emergency rooms and are admitted to acute care with less than optimally planned care. While specialist palliative care services are available in acute care, such a model, alone, cannot meet current and future demands.

Suggestions on how administrators or policy maker could use the findings (up to 3; brief bullet points)

• The implementation of a palliative care referral criteria instrument across departments has the potential to lessen ‘silo-ing’ of care and positively impact goals of care conversations
• Providing leadership and support to implement advance care planning conversations may decrease the number of unnecessary interventions
• Support and education in palliative approach to care for health care staff can improve confidence and competence addressing issues of burden and burn-out

Study Summary

In this research we used participatory research approaches and worked with staff on one acute care medical unit to integrate a palliative approach into their practice. Specifically we worked with the health care team on the unit to: (1) explore their beliefs, assumptions and practices around care for older adults with life-limiting illness on their unit; (2) share information and evidence about a palliative approach, the potential benefits for patients, families, providers and the healthcare system and key ingredients for care delivery; (3) develop and implement strategies to integrate a palliative approach into their work; and (4) evaluate these strategies and their influence on patient and family outcomes. It is recognized that traditional models of specialized palliative care in acute care are not effective in achieving significant population and system-level improvements.

Key Findings

• Over-interventionist focus in acute care along with a general discomfort in talking with patients and families about end-of-life care can lead to poor quality care at the end of life.
• Adopting key components of a palliative approach to care can have qualitative benefits for patients and their family caregivers and the staff who provide care for them.
• Integration of a palliative approach to care (PAC) requires strong unit leadership, skilled facilitation and capacity building among team members, receptivity to change, and adapting and embedding tools into usual care processes.

Evidence gap addressed by study/Why this study was needed

Despite evidence that most people prefer to die at home, acute care functions as the major provider of end of-life care in Canada. Research suggests up to 35% of hospital inpatients have palliative care needs, but these needs are often unaddressed, with patients receiving poor quality care. While specialist palliative care services are available, such a model, alone, cannot meet current and future demand.

Brief overview of the methodology

Using a participatory action research model, clinical nurse leaders identified principal actors on one medical unit across all disciplines (OT, health care aide, RNs, management) and provided them with intensive support and education in PAC for three months. The principal actors then worked with other staff and clinical positions to integrate PAC practice across the unit. Over a six-month action cycle process, strategies for integration of a PAC were implemented. While core processes for integrating a palliative approach evolved over the course of the project, key components of a palliative approach intervention were identified collaboratively by the research team and action team members (figure above). They included:

• Identification of patients who could benefit from a palliative approach
• Person-centered (patient and family) quality of life assessment: physical, social, spiritual, and emotional
• Education and mentoring on disease trajectory/prognosis awareness, serious illness conversations
• Fostering the capacity for appropriate pain and symptom management
• Care focused on patients’ beliefs, values and goals and support of family members

Potential impact of findings on clinical practice/patient care and how this impact might be measured

• Identification of patients who could benefit from a PAC is a key mechanism is empowering patients and families in advocating for appropriate care.
• Health care providers need to increase their fluency in palliative care language and comfort with conversations regarding illness trajectories.
• Health authorities and hospital administrators provide essential leadership in identifying a PAC as a priority.

Remaining knowledge/research gaps

• Identification of patients who could benefit from a PAC is a key mechanism in empowering patients and families towards making informed health care decisions and advocating for appropriate care.
• ‘Silo-ing’ of systems results in a lack of communication between sectors or departments, such as home care, residential care, emergency, pharmacy, etc. which results in higher workloads, diversion of energy away from bedside care, and discontinuity of care.

CFN Webinar (December 4, 2019): Integrated Approach to Palliative Care in Acute Care (iPAC-AC)