Authors (including presenting author) :
Kwan SCW(1)(3), Tam KFS(2)(3), Lee MM(1)(3), Wong FS(1)(3), Tang KL(1)(3), Cheung HYS(1)(3), Kwan HY(1)(3), Ip KY(1)(3), Au CK(1)(3), Siu KY(1)(3)
Affiliation :
(1)Nursing Services Division, (2)Department of Medicine, (3)Hong Kong Buddhist Hospital
Introduction :
414 medical patients passed away in 2021 at HKBH and only 18 (4.35%) opted for active resuscitation, implying that most patients require comfort care to go through the end-of-life (EOL) process. Nurses often express frustration with the excessive interventions for the dying patients. With the regular rotation of medical doctors from acute hospital, a nurse-led EOL care program is therefore piloted in a convalescent medical ward to enhance the quality of care with a multidisciplinary approach.
Objectives :
(1) to promote physical comfort of the dying patients; (2) to provide psychological support for the dying patients and their families; (3) to reduce unnecessary interventions; (4) to enhance staff satisfaction in providing EOL care.
Methodology :
An EOL care program was piloted in a 84-bed medical ward from 3 October 2022 to 31 March 2023. After the initial screening by nurses, suitable patients were recruited when consensus is obtained from the family on the decision of ‘Do Not Attempt Cardiopulmonary Resuscitation’. A cue card, serving as a care protocol, was inserted into the medical record of the patients like a bookmark which aroused the attention of the multidisciplinary team to stop or reduce unnecessary interventions, including vital signs measurement and investigations like blood tests and radiological examinations to promote comfort of the dying patients. To obtain baseline information for comparison, medical records of all patients who passed away in the pilot ward in 2021 had been reviewed. Work satisfaction among nurses would be explored before and after the pilot by using the Moral Distress Scale-Revised (MDS-R).
Result & Outcome :
From Oct 2022 to Feb 2023, 68 patients passed away in the pilot ward compared to 113 for the full year of 2021. 21 patients were recruited for the EOL program, 17 (81%) female and 4 (19%) male, with an overall mean age of 87.1 years. Absolute reduction had been observed in the following: 1. Patients on vital signs monitoring at least 4 times a day reduced 40.5% (from 92.9 to 52.4%). 2. Patients on regular glucose monitoring throughout their hospitalization reduced 69% (from 78.2 to 9.1%). 3. Patients who had blood tests reduced 13.9% (from 42.5 to 28.6%) and those who had radiological examination reduced 13.1% (from 27.4 to 14.3%) in the last 48 hours of life. 4. Patients with nasogastric tube feeding reduced 17.3% (from 36.3 to 19%). In 2021, 64.6% of patients or their families opted for careful hand feeding, compared to 81% in the pilot group. EOL care including feeding options were explained to the family with support provided for the decisions they made in the best interest of the patient. Percentage of patients who received subcutaneous, instead of intravenous, fluid to maintain hydration increased from 2.1% to 35%. The use of physical restraints had been reduced from 43.4% to 28.6% of patients. Baseline MDS-R results obtained from 45 nurses working in the pilot ward showed the highest scores, reflecting a higher level of moral distress, in the following: ‘Follow the family’s wishes to continue life support even though it is not in the best interest of the patient’, ‘Follow the family’s request not to discuss death with a dying patient who asks about dying’, ‘Initiate extensive life-saving actions when I think they only prolong death’, and ‘Carry out the physician’s orders for what I consider to be unnecessary tests and treatments’. Conclusions: The baseline MDS-R results demonstrated that nurses were dissatisfied with the excessive interventions for the dying patients initiated either by the family or the physician. Preliminary results of the pilot showed that unnecessary interventions could be minimized to maximize comfort for the dying patients. It is quite promising that this program can be rolled out to all medical patients requiring EOL care in HKBH.
