• Posted January 17, 2024

'Default' Orders for Palliative Care Speed Relief for Hospital Patients in Pain

Palliative care is meant to ease suffering at any stage of disease, but too often many patients wait too long for this type of care to be ordered.

Now, researchers at the University of Pennsylvania may have come up with a solution: Make consultations regarding the need for palliative care a "default" part of hospital care, giving more patients quick access if it's needed.

As explained in a UPenn news release, this would mean setting up "an automatic order programmed into the electronic medical record that doctors may cancel if they choose" -- but it is always there if they don't.

After instituting this system across 11 hospitals, palliative care consultation rates rose from 16.6 percent of cases to 43.9 percent, researchers report. Patients also saw an average 1.2-day decrease in the time they had to wait for such a consultation.

"We found that a simple, pre-programmed order within the electronic medical record can get more palliative care to more people more quickly,” said study lead author Dr. Kate Courtright, an assistant professor of critical care and palliative medicine.

“This strategy was low-cost and easily implemented in community hospitals, which is where most Americans receive their health care," Courtright said.

The study was published Jan. 16 in the Journal of the American Medical Association.

As the researchers explained, palliative care is not just for the end of life.

In the news release, it is defined as "specialized medical care focused on relieving the symptoms and stress of a serious illness and improving quality of life, in alignment with a patient's individual goals, values and priorities."

While many people think of palliative care as something ordered for patients with cancer or end-stage heart failure, it's also extremely valuable for those struggling with other illnesses such as dementia, kidney failure or chronic obstructive pulmonary disease (COPD).

Too often, these patients suffer from breathlessness, anxiety and pain that a palliative care approach could ease, the researchers explained.

Having to formally ask for a consultation regarding the need for palliative care can be a roadblock to getting it quickly.

The new study involved over 34,000 patients with COPD, dementia or kidney failure treated at 11 hospitals in eight states. Each hospital already had a palliative care program in place.

During the 2016-2018 study period, hospitals began with their standard protocol (no default to automatic consultations) and then transitioned to protocols where automatic consultations were the norm. Clinicians were also free to still order a consultation on their own.

Courtright's team found that default consultation orders were cancelled by doctors less than 10% of the time.

“Our results suggest that the default order strategy was generally acceptable to clinicians, which is important because if we want to reach as many eligible patients as possible, we need to design approaches that are feasible for 'real-world' practice and not just in the research setting,” Courtright said.

Her team found that, even with the default orders in place, patients still only received a palliative care consultation in about half of cases, perhaps because of staffing issues.

Among those patients who did get a consultation thanks to the default order, the time needed for hospital care was shortened by almost 10%, on average.

Implementing the default-order system appeared to raise the number of patients who were transferred to hospice care, with no increase in deaths while in hospital, the study found.

That suggests a better focus on patient care, quality of life and improved end-of-life care, the team said.

Future studies are planned to see if systems can be improved even further.

“As we build on this work, our goal is to continuously improve inpatient palliative care so that all patients and families facing a serious illness have access to the support they need to carry on with their daily lives throughout their treatment journey," said senior study author Dr. Scott Halpern, a professor of medicine, epidemiology, and medical ethics and health policy at UPenn.

More information

There's more on palliative care at the National Institute on Aging.

SOURCE: University of Pennsylvania, news release, Jan. 16, 2024