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Tracheotomy is performed on patients with airway obstruction or prolonged mechanical ventilation. Tracheotomy patients are increasingly being referred to hospice and palliative care. This case series describes a process for evaluating the ongoing need for tracheotomy and the impact of tracheotomy removal. A retrospective cohort design was used in which charts were reviewed of all tracheotomy patients referred to the palliative care unit between November 1, 1998, and July 31, 2001. Tracheotomy was present in 13 of 791 palliative care unit admissions. Persistent airway obstruction contraindicated tracheotomy removal in 5 patients. The remaining patients had a successful “button” trial with subsequent tracheotomy removal. They incurred no complications and exhibited improved functional status and decreased symptom burden. Tracheotomy removal is safe and beneficial in this patient subset and should be considered an alternative to prolonged tracheotomy.

Objective: To identify factors associated with internal medicine interns' self-assessed competency in death pronouncement and to evaluate the effectiveness of a 10-minute death pronouncement module and pocket card guidelines.Methods: In June 2003 at the Birmingham VAMC, Alabama, 48 internal medicine interns completed a survey of medical school education, training, and experience in death pronouncement and a self-assessment of death pronouncement competency. In September 2003, 33 of the 48 interns completed a follow-up training/education survey and rated their post-intervention competency. Using chi-square and paired t-tests, we identified factors associated with variations among baseline and post-intervention variables and examined pre-post changes in self-assessed competency levels.Results: At baseline, less than 30% of the interns had medical school instruction in the process of death pronouncement. More than 70% reported needing basic instruction/close supervision. Post-intervention, close to 90% interns needed minimal or no assistance. Over 50% reported using pocket card guidelines. We found significant pre-post increases in mean rankings in each of the 5 self-assessed competencies (p < .001). Factors associated with differences in baseline and post-intervention assessments included medical school training/experience and use of the pocket card guidelines.Significance of results: When interns began training, most had no instruction in death pronouncement and felt unprepared for this task. With brief instruction, pocket card guidelines, and 3-months experience, the majority of interns reported needing minimal/no assistance in pronouncing death. A larger sample from multiple sites is needed to confirm these findings.

Known for excellence in care in the last days and hours of life, hospice programs can help individuals have a "good death" and lead to higher family satisfaction with quality of care. Our objective was to evaluate the effectiveness of a multicomponent palliative care intervention based on the best practices of home hospice and designed to improve the quality of care provided for patients dying in an acute care inpatient setting.This study was a before-after intervention trial conducted between 2001 and 2003. Participants included physician, nursing, and ancillary staff on inpatient services of an urban, tertiary care Veterans Affairs medical center. The palliative care intervention included staff education and support to identify patients who were actively dying and implement care plans guided by a comfort care order set template for the last days or hours of life. Data abstracted from computerized medical records of 203 veterans who died during a 6-month period before (n = 108) and after (n = 95) intervention were used to determine the impact of intervention on symptom documentation and 5 process of care indicators.There was a significant increase in the mean (SD) number of symptoms documented from 1.7 (2.1) to 4.4 (2.7) (P.001), and the number of care plans increased from 0.4 (0.9) to 2.7 (2.3) (P.001). Opioid medication availability increased from 57.1% to 83.2% (P.001), and do-not-resuscitate orders increased from 61.9% to 85.1% (P.001). There were nonsignificant changes in the proportion of deaths that occurred in intensive care units (P = .17) and in the use of nasogastric tubes (P = .40), and there was a significant increase in the use of restraints (P.001).Our results indicate that end-of-life care improved after the introduction of the palliative care program.

direct admission process and increased the frequency of verbal communication between medical providers. Background. Transitions in care are vulnerable times for patients. Standardizing workflows and communication between medical providers is thought to decrease the risk of adverse events. When transferring patients from our hospital to an inpatient hospice facility, our Palliative Care physicians are able to directly admit patients without having a separate hospice admission nurse visit to assess the patient and facilitate the transfer. This can expedite the transfer out of the hospital for patients, but some physicians are less familiar with implementing this process than others, leading to concerns about increased risk of adverse events. Research Objectives. Design and implement a standardized checklist to improve physician comfort with performing direct admissions of patients from our hospital to an inpatient hospice facility and physician communication during the transition of care. Method. We developed a checklist tool for patients being directly admitted to an inpatient hospice facility from our hospital. Preand post-intervention surveys assessed physician comfort with directly admitting patients to the inpatient hospice facility and quantified the number of verbal hand-offs given to the accepting hospice physician. Result. We surveyed seven hospital palliative care physicians. After implementation of the checklist, the mean reported comfort level with completing the direct admission process improved from 3.14 to 4 (Likert Scale, 1-5), the mean number of verbal hand-offs per month increased from 6.33 to 13.5, and the mean number of verbal hand-offs per person per month increased from 1.03 to 2.25. Conclusion. This study suggests that implementation of a standardized tool to facilitate transitions in care between a hospital and an inpatient hospice facility increases physician comfort level with the process and increases the frequency of verbal hand-offs to accepting physicians. Implications for Research, Policy, or Practice. This standardized checklist tool can be adapted for use at other institutions to help improve workflow and communication during transitions of care. We Thought We Had More Time: Exploring Next-of-Kin Accounts of Hospice and Palliative Care Discussions for Veterans Who Died in VA Medical Centers (S766) Beverly Williams, PhD, University of Alabama at Birmingham, Birmingham, AL. F. Amos Bailey, MD, University of Alabama at Birmingham/Birmingham VA Medical Center, Birmingham, AL. Lesa Woodby, PhD MPH, Birmingham VA Medical Center, Birmingham, AL. Angelina Wittich, PhD MPH, Birmingham VA Medical Center, Birmingham, AL. Kathryn Burgio, PhD, University of Alabama at Birmingham, Birmingham, AL. (All authors listed above had no relevant financial relationships to disclose.)

The Balm of Gilead is a comprehensive program of end-of-life care for the populations served by the "safety net" public health system in Alabama's largest county. The Balm of Gilead serves terminally ill persons, predominantly of minority ethnic status who as a group are relatively younger than the national hospice population, and typically lacking in personal financial resources. Care provided by the Balm of Gilead addresses the holistic needs associated with terminal illness in each of its stages and each of its treatment settings. Balm of Gilead professionals and volunteers provide continuity of care across a continuum that includes inpatient palliative care, home hospice services, and specialized palliative care in nursing homes and other community residential settings. Cooper Green Hospital and the Jefferson County Department of Health are principal partners in the program. Community partnerships with local foundations, colleges and universities, faith communities, civic groups, and professional groups complete the collaborative network of the Balm of Gilead Project. This report discusses work to date toward fulfilling the project's two primary objectives: (1) to build the infrastructure necessary to support a comprehensive palliative care program that is available to county residents regardless of their ability to pay and (2) to develop systems and services to foster the institutional and community values that promote excellence in end-of-life care. The Project's current status and future challenges are reviewed.

Patients with congestive heart failure (CHF) account for up to 12% of the hospice population and often experience significant symptoms related to volume overload. Diuretic therapy is the cornerstone of treatment but administration (PO) often becomes ineffective and (IV, IM) routes cause discomfort or may not be feasible to ameliorate symptoms. Subcutaneous dosing of furosemide has been explored as a potential alternative for management of CHF symptoms. We report 2 cases of CHF resistant to oral diuretic and examine the clinical utility of subcutaneous furosemide in an inpatient palliative care unit and a home hospice setting. Our case series supports the use of subcutaneous therapy as a potential alternative in palliative care and hospice patients.

Result. Two broad thematic categories were identified: what the students learned and what the students experienced. Student writings revealed learning about palliative care (pain management, family meetings, goals of care, patientfamily centered care, timing of palliative care, and delivering bad news); being a doctor (knowledge, communication, presence, empathy, not giving false hope, and person-focused care); the patient (importance of family, the experience of dying, and the uniqueness of each patient); and themselves (need to be non-judgmental, ability to do palliative care, self-limitations, becoming a better physician, and dealing with death). Student reflections centered on encounters with patients and families, internal emotional responses, and self-transformation.

Health System & Temple University, Pittsburgh, PA. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, University of Texas Health Science Center San Antonio, San Antonio, TX. Sandra Sanchez-Reilly, MD, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX. (All speakers have disclosed no relevant financial relationships.)

Pain and Practicalities: The Experience of Transitioning a Young Cancer Patient from High-Dose Hydromorphone Therapy to Intravenous Methadone in an Academic Medical Center (736) Virginia LeBaron, MS ACNP-BC ACHPN, University of Arizona, Tucson, AZ. Jacqueline Brody, PharmD, University Medical Center, Tucson, AZ. Ellyn Lee, MD, University of Arizona, Tucson, AZ. Linda Snyder, MD, University of Arizona, Tucson, AZ. (All speakers have disclosed no relevant financial relationships.)