According to a new study published in JAMA on Jan. 16, ordering a palliative care consultation via an automatic order programmed into the electronic medical record that doctors can cancel if they choose gave more hospitalized patients the opportunity to benefit from palliative care, and sooner.
Traditionally, the process for ordering palliative care consultation worked the other way around – doctors had to opt in and actively place an order. Studied here by researchers from the Perelman School of Medicine at the University of Pennsylvania was the opposite method, as doctors instead had the opportunity to opt out of an automatic order if need be. The investigators “increased palliative care consultation rates from 16.6 percent to 43.9 percent and decreased the time to consultation by 1.2 days.”
Lead author Kate Courtright, MD, MS, an assistant professor of Critical Care and Palliative Medicine, said that “a simple, pre-programmed order within the electronic medical record can get more palliative care to more people more quickly…This strategy was low-cost and easily implemented in community hospitals,” paving the way for more patients with “chronic serious illnesses [to] better understand their diagnosis and align their treatment choices to their individual care goals.”
The study included “more than 34,000 patients with chronic obstructive pulmonary disease (COPD), dementia, or kidney failure at 11 hospitals in eight states.” Palliative care is recommended for millions of Americans with serious illnesses, but a huge segment of those patients is “not referred to palliative care or only receive a consultation at the end of life.” People with these conditions are historically underrepresented in palliative care studies even though they often suffer from symptoms, like “breathlessness, anxiety, [and] pain,” that can be addressed through palliative care.
The 11 hospitals involved in the study were “neither encouraged to nor prohibited from increasing or decreasing palliative care staffing during the study” in order to “keep the study as realistic as possible.” Over the course of the study, “the hospitals began enrolling patients to the study under usual care (data collected, but no intervention) and transitioned to the intervention phase (default orders via the electronic health record) over time, in a randomly determined order. During the intervention phase, clinicians canceled the default for fewer than 10 percent of patients for whom it was generated.”
The study found that “even in the intervention group, less than half of patients actually received a consultation from a palliative care specialist.” Anticipating this, the authors also found that “for patients who only received palliative care consultation thanks to the default order, such care reduced the median length of stay by 9.6 percent. Additionally, the default orders led to more patients being discharged from the hospital to hospice care without affecting mortality, suggesting that such orders improved the quality and patient-centeredness of end-of-life care.”
The researchers already have another study planned to “test a strategy that includes training and prompting generalists who make up a patient’s primary hospital team—including nurses, advanced practice providers, physicians, and social workers—to provide palliative care themselves.”
Penn Medicine’s website has the release.
