Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Improving End-of-Life Outcomes in Nursing Homes by Targeting Residents at High Risk of Mortality for Palliative Care: Program Description and Evaluation

Authors: Levy C, Morris M, Kramer A

Journal: Journal of Palliative Medicine (2008); 11(2):217–225

DOI: 10.1089/jpm.2007.0147

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✅ PICO Analysis

Type of Study:

Retrospective, quasi-experimental pre–post chart review evaluation of a quality improvement intervention

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P – Population

• Setting:One urban, for-profit, 160-bed nursing home in the United States with Medicare, Medicaid, and private pay residents
• Participants:
  • 72 nursing home residents who died in the year before (n = 27) and the year after (n = 45) implementation of the intervention
  • Residents identified as high risk of death based on a validated mortality prediction score derived from Minimum Data Set (MDS) variables
• Risk Stratification Tool:
  • MDS-based score covering: weight loss, male sex, functional impairment, swallowing problems, dyspnoea, age >88, BMI <22, CHF diagnosis
  • Score ≥7 corresponded to ≥50% 1-year mortality risk

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I – Intervention

• Making Advance Planning a Priority (MAPP) Program, including:
  1. Weekly identification of residents at high risk of death (mortality score ≥7)
  2. Faxed physician notification including 4 response options:
     • Already addressed
     • Will address at next visit
     • Refer to palliative care
     • Refer to hospice
  3. Use of trained social workers to discuss options with families and facilitate palliative/hospice referral
  4. Standardised use of the Nursing Homes and Life-sustaining Options for Treatment (NHoaLOT)advance care planning tool to elicit preferences across 5 clinical scenarios and 6 interventions (e.g., CPR, ventilation, tube feeding)

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C – Comparison

• Comparator:
  • Pre-implementation residents who died in the nursing home in the year before the MAPP intervention (retrospective controls)

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O – Outcomes

Person-Centred Outcomes:

• Advanced directive completion:
  • 100% post-implementation vs 88% pre-implementation (p = .03)
  • DNR orders: 84.4% post vs 63.0% pre (p = .003)
• CPR preferences: More comprehensive, specific discussions were elicited via the NHoaLOT tool

Process Outcomes:

• Palliative care referrals:
  • Increased from 7.4% to 31.1% (p = .02)
  • Mean palliative care days increased from 1.0 to 13.8 (p = .09)
  • Hospice referrals unchanged (40.7% vs 40.4%)
  • Combined hospice/palliative care referrals rose from 44.4% to 66.7% (p = .06)

Health System Outcomes:

• Site of death:
  • Hospital deaths decreased from 48.2% to 8.9% (p < .0001)
  • No significant change in number of days in hospital before death (5.17 vs 3.33; p = .42)

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Summary Conclusion

The MAPP program, which targeted nursing home residents at high risk of death using a validated prognostic tool and facilitated timely advance care planning and palliative care referrals, significantly improved end-of-life outcomes. These included increased advance directive documentation, more palliative care referrals, and a marked reduction in terminal hospitalisations. The intervention was feasible in a single facility with strong leadership and hospice collaboration, though generalisability may be limited due to setting-specific factors .

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