Let's Talk: A Data-Driven Dialogue on End-of-Life Choices

After spending close to two decades working in home care, Suzanne Sullivan, MBA, RN, wanted to make an impact on patient care in the community, so when it came time for her to choose a dissertation topic for her PhD program, she needed to look no further than her extensive nursing career experience to find her focus.

Sullivan has witnessed firsthand just how difficult it is for patients and their families to discuss and plan for end-of-life care. As a longtime director in a quality improvement department, she identified the need to equip home health nurses with assessment tools necessary to help identify those patients most at risk for repeated interventions in both inpatient and outpatient settings. According to data from the 2004 “National Nursing Home Survey” and the 2007 “National Home and Hospice Care Survey,” only 28 percent of home health care patients, 65 percent of nursing home residents and 88 percent of hospice care patients have an advance directive on record (as cited in Jones, Moss, & Harris-Kojetin, 2011). Sullivan’s goal is to assist these patients and their families by providing information to help make informed decisions about their advance care directives.

Targeting frail elders with multiple chronic illnesses who are at risk for imminent decline in their health status, Sullivan plans to use the federally mandated Home Health Outcome and ASsessment Information Set (OASIS) dataset to develop a predictive model to assist with identifying at-risk patients. Through the development of a clinical algorithm to be incorporated into the electronic medical record, she aims to set up a system that detects and alerts home health nurses to patients at risk for death within 12 months. This system would allow nurses to initiate meaningful conversations with the patients and their families regarding their desires for end-of-life care and create a proactive, patient-centered care plan with clinical decision support to help manage their complex care.

While lack of time is often cited as a major barrier to advance care planning, nurses must be encouraged to make this a priority in order to improve communication between patients, their families and their trusted health care providers. Spending time discussing their end-of-life wishes offers patients the opportunity to receive health care treatment consistent with their cultural values and ensures access to quality end of life care. By starting the conversation and nurturing the discussion, patients and families are empowered to make informed, thoughtful decisions and take charge of their lives to assure that they are receiving quality end-of-life care.

- DONNA A. TYRPAK