Critical Path Network: Palliative care program uses self-assessment tool
Critical Path Network
Palliative care program uses self-assessment tool
By Patricia J. Sawicki, MS, RN
Clinical Nurse Specialist
Eileen Nahigian, MS, RN C
Director, Advanced Practice Nursing
Buffalo General Hospital/Kaleida Health
Buffalo, NY
The Kaleida Health Palliative Care Consultation Service (PCCS) originated with physician and administrative interest in providing a consultative service to inpatients with potential expansion to the outpatient area. Traditionally, palliative care has meant treatment of symptoms for terminally ill patients. "[However], programs are expanding the concept to cover all seriously ill people, including those with chronic ailments for whom relief is viewed as part of good medical care."1
As at Beth Israel Medical Center in Boston, the Kaleida Health Program was to be based upon the concept of expanding the population served to include chronic illness. The service consists of a part-time nurse practitioner, a part-time clinical nurse specialist in behavioral health, and a part-time collaborating medical physician. The Kaleida Health approach is physician-directed with nurse coordination.
The primary features of the PCCS are the assessing and managing physical symptoms, assisting patients to identify personal goals for end-of-life care, assessing and managing psychological and spiritual needs, and planning patients’ discharge. The PCCS functions in a consultative capacity with the attending physician so the patient can remain under the care of the primary physician.
"Outcome measures are not based on hard data such as biochemical indices or survival, which are relatively easy to quantify, but on changes in symptoms and quality of life, which are more difficult to measure."2 D. Doyle states. This is particularly true with palliative care patients. We had believed that patients managed by PCCS experienced a measurable improvement in the perception of physical and psychological distress sooner than similar patients who were not managed by the PCCS.
According to I. Higginson,3 methods and audit tools are available and have been tested for clinical audit, especially the support team assessment schedule and the Edmonton symptom assessment system (ESAS). The ESAS appears to capture the key outcome indicators through the patient’s perception.
By utilizing this tool, the palliative care consultation team is placing more emphasis on patient responses than on the illness or disease. Since we did not have a documentation tool that would capture symptoms and their progression, we introduced the ESAS tool. We conducted a nonexperimental, descriptive, prospective study of patient outcomes using the ESAS to confirm our hypothesis.
Instrument
The ESAS tool was developed by E. Bruera4 to assess palliative care by assisting the patient to identify his/her symptoms. These key symptom indicators are a group of physiological and psychological symptom complexes consisting of appetite, depression, drowsiness, well-being, nausea, pain, shortness of breath, and tiredness. The ESAS has two formats: The first is a visual analogue scale that is 100 mm long. The patient marks where the symptom falls between the two extremes. The second is a numerical scale from 0-10 where the patient circles the most appropriate number to indicate the score between these extremes.
The 0-10 scale was used for this project. In addition to the nine symptom distress indicators listed on the tool, the ESAS provides a space for "other symptoms." Although we assessed and documented "other" symptoms, we found that the tool itself addressed most symptoms for the majority of patients.
Requests for PCCS consultation are considered for patients who meet one of the following criteria:
- have a life-limiting/threatening condition with decline in functional status or cognitive functions;
- independent of prognosis, have suboptimal control of pain or other distressing symptoms;
- because of age, fragility, or comorbid health factors, decline further invasive or curative procedures, preferring comfort-oriented symptom management.
Sample
A convenience sample was studied from those patients referred to PCCS who were cognitively aware, who could verbally communicate, and who signed an informed consent. Cognitive awareness was judged based on an investigator-developed screening tool. Verbal communication was necessary so that the patient could self-report symptoms to the rater. When a patient could not independently score symptoms, a staff member or a family member could complete the tool.
However, after testing the tool on five patients, we felt that the most reliable data would be obtained directly from the patient. Therefore, we limited subjects to those who could communicate their scores to us. This resulted in a small sample (26 of 133 PCC patients).
There actually were 31 patients who met all of our criteria but chose not to participate for a variety of reasons. During the time period of the study, the PCCS team received 133 referrals. Of those, some were unable to communicate (e.g., ventilator-dependent, cognitively impaired) and some preferred not to participate. A resultant sample of 26 patients completed the study. (See table 1.)
Table 1. Sample Demographics Summary | ||||
Age Range: 26 to 92 (Mean 67.85) | ||||
N = 26 |
N = 13 |
|||
Gender: | Female | 13 | Female | 7 |
Male | 13 | Male | 6 | |
Race: | Caucasian | 19 | ||
African American | 6 | |||
Native American | 1 | |||
Diagnosis: | Oncology | 11 | Oncology | 7 |
Renal Failure | 3 | Renal Failure | 2 | |
Peripheral Vascular Disease | 4 | Peripheral Vascular Disease | 1 | |
Orthopedic | 3 | Orthopedic | 1 | |
Pancreatitis | 2 | Pancreatitis | 1 | |
Coronary Artery Disease | 2 | |||
Other | 1 | Other | 1 | |
Data collection
Following institutional review board approval, informed consent was obtained from all subjects. A cognitive orientation screening was initially performed with each participant to ascertain the patient’s ability to answer the questions on the ESAS tool. To maintain consistency and increase interrater reliability, three registered nurses were trained in the administration of the tool and adherence to its guidelines.
The ESAS scale was completed on the day of referral to PCCS and on days three and five thereafter. Thirteen of the 26 completed records were randomly selected by the SPSS computer program. The descriptive nature of the data gathered with the use of the ESAS lends itself to measures of frequency distribution and central tendency. Descriptive data were provided from days one, three, and five.
Paired sample t-tests were performed comparing day one with day three and day one with day five. Significant improvement was observed in four indicators on day three, namely appetite, depression, pain, and tiredness. (See table 2.)
Table 2. Paired Samples Test | ||||||||
Paired Differences |
||||||||
Mean | Standard Deviation | Standard Error Mean | 95% Confidence Interval of the Difference | T | Df | Sig.
(2- tailed) |
||
Lower |
Upper |
|||||||
Pair 2 | ||||||||
Appetite 1 to Appetite 3 | 1.77 | 2.74 | .76 | .11 | 3.43 | 2.325 | 12 | .038 |
Pair 3 | ||||||||
Depression 1 to Depression 3 |
2.54 | 3.07 | .85 | .68 | 4.39 | 2.98 | 12 | .011 |
Pair 7 | ||||||||
Pain 1 to Pain 3 |
2.46 | 3.28 | .91 | .48 | 4.44 | 2.704 | 12 | .019 |
Pair 9 | ||||||||
Tired 1 to Tired 3 |
2.08 | 2.5 | .69 | .57 | 3.59 | 2.997 | 12 | .011 |
On day five, three indicators showed significant improvement, namely depression, pain, and tiredness. (See table 3.)
Table 3. Paired Samples Test | ||||||||
Paired Differences |
||||||||
Mean | Standard Deviation | Standard Error Mean | 95% Confidence Interval of the Difference | T | Df | Sig.
(2- tailed) |
||
Lower |
Upper |
|||||||
Pair 3 | 2.81 | 2.112 | 12 | |||||
Depression 1 to Depression 5 |
1.62 | 2.06 | .57 | .37 | 2.86 | 2.823 | 12 | .015 |
Pair 7 | ||||||||
Pain 1 to Pain 5 | 2.85 | 2.88 | .80 | 1.10 | 4.59 | 3.56 | 12 | .004 |
Pair 9 | ||||||||
Tired 1 to Tired 5 | 2.31 | 1.84 | .51 | .1.19 | 3.42 | 4.514 | 12 | .001 |
This descriptive study has illuminated the benefits of a specialized palliative care team focusing on the physiological and psychological needs of a patient population with a chronic illness or in need of end-of-life care. A significant improvement in the areas of depression, pain, and level of tiredness was perceived by the patients in this study from day one to day five.
Our original intent was to construct an experimental design with a comparison group. However, we did not have access to comparable patients who were not referred to PCCS. The determination of criteria for a comparison group and access to this patient population were restricted at the time of the study.
Results
It appears that this tool is useful with those patients who can relate symptom distress scores. However, with noncommunicative patients where objective assessment is required by staff or family members, the tool poses additional challenges. Further research is indicated in this area in order to determine the impact of a palliative care team on patient outcomes and patient/ family satisfaction. A follow-up study is indicated in order to involve a comparison group and increase sample size.
(The authors would like to acknowledge the Palliative Care Consultation Team: Robert Milch, MD, Medical Director; Patricia Murphy, MS, NP, Coordinator; and Doris Clark, BS, RN, Staff Member and Student Volunteer.)
References
1. Greene J. A better ending. Hospitals and Health Network 2000; 3:86-172.
2. Doyle D, Hanys G, MacDonald N. Oxford Textbook of Palliative Medicine. New York City: Oxford University Press; 1998.
3. Higginson I. Clinical audit and organizational audit in palliative care. Cancer Surveys 1994; 21:233-245.
4. Bruera E. The Edmonton symptom assessment system (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care 1991; 7(2):6-9.
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