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An End-of-Life Checklist
James Downar, MDCM, MHSc, FRCPC
Critical Care and Palliative Care,
University Health Network, Toronto
Conflicts of Interest
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You are on service with the RRT…9pm
• 65M- Metastatic NSCLC• Relapse- no chemo/radio option
• Pneumonia- 3d abx
• RRT- RR>30, O2 sat 90% on 40% FM• Short sentences
• After discussion - no ICU, no intubation
• RRT to follow for 24h
• Did we improve his EOL care?
What is a “good death”?
• “…free from avoidable distress and suffering for
patients, families, and caregivers; in general accord
with patients’ and families' wishes; and reasonably
consistent with clinical, cultural, and ethical
standards.”
» Institute of Medicine (1997)
A “Good” Death
• Things to start
• Things to stop
Recognition that death is coming
• Patient/family
• Physician/HCP
Discussion
• Appropriate Goals
Plan of Care
• Realistic
• Concordant with goals
Use of Palliative Care Resources
• Inpatient
• Outpatient
“Good Death”
• Symptom control
• Non-acute setting
• Support for pt/family
Do we stop and start things appropriately?
• Review of 300 consecutive RRT referrals• 24 (8.3%) – Family meeting, new DNR
• 80% called for classic ABC criteria, 63% died
• 2 patients died without EOL meds or consultations
Downar et al. J Crit Care In Press.
Time Palliative
Care
Spiritual
Care
PRN
Opioids
PRN
Sedatives
Next 48h 17% 8% 17% 8%
Entire
Admission
29% 12% 75% 42%
Are there Gaps in EOL Care?
• Turning off an ICD after DNR - 27%• 8% shocked <1 hr from death
• Advance care planning in adult
congenital heart disease - 2d from
death• 50% die receiving CPR
• How can we remember to address all of
this?
Ann Intern Med 2004;141:835-8.
Tobler et al. Pall Med 2012;26:72-9.
WHO’s Safe Surgery Saves Lives Program
• 19-Item Surgical Safety Checklist
• Reduced mortality (1.5% to 0.8%)
• Reduced surgical complications (11% to 7%)
• Follow-up studies
• Reduced mortality (9%), complication rate
(10.6%)
Haynes et al. NEJM 2009;360:491-9.
De Vries et al. NEJM 2010;363:2124-34.
Julia et al. NEJM 2010;304:1693-1700.
Going viral…safely
• Surgical safety checklist• Ontario Hospital Balanced
Scorecard (2011) - 30%
• France- all 8000 hospitals (2010)
• Central line insertion
checklist• Rhode Island- All ICUs
Weiss and Downar. Unpublished
What is a checklist?
• Tool• Translate research into practice
• Goals (“Culture change”)• Standardize diagnosis and management
– Code stroke
• Adherence to guidelines– “CLI bundle”
• Increase efficiency– Admission order set
• Objective• Reduce mortality, morbidity
• Improve satisfaction
Pronovost. Safe Patients, Smart Hospitals. New York. Hudson Street Press. 2010.
Checklists
• Meta-analysis of 18 studies • Mostly before-after, no RCTs
• Variety of populations, disease states
– Findings
• Poor quality
• Generally good uptake, adherence to guidelines
• Improvements in mortality, LOS, costs
– “…further investigations to formally evaluate
the effectiveness of order sets would be highly
valuable…”
Chan et al. Int J Tech Assess Health Care 2012;28:235-40.
Common pitfalls of checklists
• Content• “…templates for efficiently practicing outdated
medicine on a widespread basis.”
• Format• Length of paper orders
• Usability of electronic orders
• Implementation• Staff awareness, approval and understanding
• Multidisciplinary input
• Hawthorne effect
Bobb et al. J Am Med Inform Assoc 2007;14:41-7.
Campbell et al. J Am Med Inform Assoc 2006;13:547-56.
Noschese et al. Qual Saf Health Care 2008;17:464-8.
Making an EOL checklist?
• Content• Updating/Improving, new evidence
• Teamwork• Change culture to remove barriers
• Roles and responsibilities
• Monitoring and Feedback• Process (ease of use)
• Outcome
Pronovost. Safe Patients, Smart Hospitals. New York. Hudson Street Press. 2010.
Robbins. Crit Care Nurs Q 2011;34:142-9.
Has it been tried yet?
• “Integrating Palliative and Critical Care”• Education - Principles of PC in ICU
• Local Champions - Role Modeling
• Academic Detailing - Barriers
• Feedback - Local Data
• System supports - Order forms, pamphlets
• Self-efficacy Theory• Knowledge
• Attitudes
• Behaviours
Treece et al. Crit Care Med 2006;34:S380-7.
Cabana et al. JAMA 1999;282:1458-65.
“Integrating Palliative Care and ICU”
• Single-centre before-after study• Improved nurse-rated QODD
• No change in family-rated QODD, FS-ICU
• Cluster-randomized trial• No change in N-QODD, F-QODD, FSICU
• Increased LOS in ICU pre-death
• Lessons• Uptake of study sites?
• Internal vs. External source of change
• Bringing palliative care clinicians to bedside
Curtis et al. AJRCCM 2008;178:269-75.
Curtis et al. AJRCCM 2011;183:348-55
Liverpool Care Pathway - ICU
• 5 Key elements• Explicit goals/key elements of care
• Facilitation of communication with pt/family
• Coordinating roles and activities of team,
patient and family
• Documentation, evaluation of outcomes
• Identification of appropriate resources
• 10-Step Implementation plan
What is the LCP? Marie Curie Palliative Care Institute
Effectiveness of some EOL pathways
• LCP• Better documentation, lower symptom burden
• Palliative Care for Advanced Disease
(PCAD)• High adherence, reduced CPR, ?use of
medications
• Bailey et al. (2005)• Increased documentation of symptoms,
availability of opioids, DNR orders
Veerbeek et al. Pall Med 2008;22:145-151.
Bookbinder et al. JPSM 2005;29:529-43.
Bailey et al. Arch Int Med 2005;165:1722-7.
http://www.telegraph.co.uk/health/healthnews/9631334/Doctors-to-investigate-use-of-controversial-Liverpool-Care-Pathway.html
PALLIATIVE
http://www.leedan.com/SF-341B.htm
Designing a “Code Palliative”
• Multidisciplinary Group• Critical Care, Palliative Care
• General Medicine, Oncology
• Nursing
• Spiritual Care
• Social Work
• Bioethics
• Local studies of dying experience, staff
attitudes/beliefs
Designing a “Code Palliative”
• Existing checklists/pathways
– MEDLINE search- 1394 articles
• Palliative Care or End of Life Care
• Medical order entry systems, Standardization,
Clinical protocols, Clinical decision support
systems
– Cochrane Review- 920 articles
– Title/Abstract review
– Google search
• 201 Articles or Web-published protocols
Chan and Webster. Cochrane Database of Systematic Reviews 2011.
What to include in a “Code Palliative”
• When to use it• Legal/policy support
• Documentation of Goals of Care
University of Calgary Goals of Care Designation
What to include in a “Code Palliative”
• Symptom order set
Dignity Therapy?• Tell me a little about your life history; particularly the parts that you
either remember most or think are the most important?
• Are there specific things that you would want your family to know about you?
• What are the most important roles you have played in life (family roles, vocational roles, community-service roles, etc)? Why were they so important to you?
• What are your most important accomplishments? What do you feel most proud of?
• Are there particular things that you feel still need to be said to your loved ones?
• What are your hopes and dreams for your loved ones?
• What have you learned about life that you would want to pass along to others?
• Are there words or perhaps even instructions that you would like to offer your family to help prepare them for the future?
• In creating this permanent record, are there other things that you would like included?
Chochinov et al. Lancet Oncol 2011;12:753-62.
What to include in a “Code Palliative”
• Psychosocial Support• Dignity Therapy
• CALM Tool
• Consultation of other specialists• Palliative Care MDs
• Spiritual Care
Chochinov et al. Lancet Oncol. 2011 August ; 12(8): 753–762.
Nissim et al. Pall Med 2012;26:713-21.
Back to our case…
• 65M- Metastatic NSCLC• Relapse- no chemo/radio option
• Pneumonia- 3d abx
• RRT- RR>30, O2 sat 90% on 40% FM• Short sentences
• After discussion - no ICU, no intubation
• RRT to follow for 24h
• Code Palliative?
