Intervention to Improve Care at Life's End (BEACON)

Intervention to Improve Care at Life's End in VA Medical Centers

The BEACON trial (Best Practices for End-of-Life Care for Our Nations' Veterans) was a six-site implementation study to evaluate a multi-component, education-based intervention to improve the quality of end-of-life care provided in VA Medical Centers.

Study Overview

• Status: Completed
• Conditions: Pain; Death; Dyspnea
• Intervention / Treatment: Behavioral: Comfort care education intervention

Detailed Description

The BEACON trial (Best Practices for End-of-Life Care for Our Nations' Veterans) was a six-site, real-world implementation trial of a multi-component, education-based intervention to improve the quality of end-of-life care conducted in VA Medical Centers (VAMCs).

The primary aim was to evaluate the effectiveness of a multi-component intervention for improving processes of care provided in the last days of life in VAMCs. The second aim was to conduct after-death interviews with next-of-kin and qualitative analysis of their perceptions of the care provided to the veteran and family.

The multi-component intervention targeted VAMC inpatient providers, including physician, nursing, and ancillary staff. It consisted of preparatory site visits, a staff training program, a newly developed Comfort Care order set decision support tool built into the CPRS, and follow-up consultation. The intervention team travelled to each site to conduct two weeks of comprehensive in-service training. Staff were trained to identify actively-dying patients and implement a set of best practices of traditionally home-based hospice care for dying patients. The team provided assistance with policies, procedures, and skill training needed to implement comfort care interventions. Introduction of the intervention at each VAMC was staggered across time at six-month intervals using a multiple-baseline, stepped wedge design.

Data on processes of end-of-life care (last 7 days) were abstracted from the CPRS medical records of all veterans who died before, during, and after the intervention (January 2005-February 2011). A priori, five processes of care were identified as primary endpoints to indicate quality of end-of-life care: 1) presence of an order for opioid pain medication at time of death; 2) a do-not-resuscitate (DNR) order in place at time of death; 3) location of death; 4) presence of enteral feeding tube or intravenous line at time of death; and 5) physical restraints in place at or near time of death.

In addition, in-depth, face-to-face interviews were conducted with 78 bereaved next-of-kin.

• Study Type: Interventional
• Enrollment (Actual): 78
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35233
      • Birmingham VA Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Aim 1: Not applicable. Patients were deceased.
• Aim 2: After-death interviews with next of kin: must be willing and able to participate in after-death interview at local VA Medical Center.

Exclusion Criteria:

• N/A

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm 1; Comfort care education intervention, consisting of intensive, on-site staff training together with an electronic order set for palliative care and educational materials	Behavioral: Comfort care education intervention; Comfort care education intervention, consisting of intensive, on-site staff training together with an electronic order set for palliative care and educational materials

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Presence of Order for Opioid Pain Medication	Presence of order for opioid pain medication at time of death based on abstraction of electronic medical record	Pre and Post Intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Do Not Resuscitate Order	Presence of a Do Not Resuscitate order at time of death based on abstraction of electronic medical record	Pre and Post Intervention
Number of Patients Who Died in ICU	Location of death (ICU vs. other) based on abstraction of electronic medical record	Pre and Post Intervention
Individuals With a Nasogastric Tube	Presence of nasogastric tube based on abstraction of electronic medical record	Pre and Post Intervention
Individuals With an Intravenous Line	Presence of intravenous line infusing at time of death based on abstraction of electronic medical record	Pre and Post Intervention
Number of Individuals Who Died in Restraints	Presence of restraints at or near time of death at time of death based on abstraction of electronic medical record	Pre and Post Intervention
Individuals Administered of Opioid Medication	Administration of opioid medication based on abstraction of medical record	Pre and Post Intervention
Individuals With an Order for Antipsychotic Medication	Order for antipsychotic medication based on abstraction of medical record	Pre and Post Intervention
Individuals Administered Antipsychotic Medication	Administration of antipsychotic medication based on abstraction of medical record	Pre and Post Intervention
Individuals With an Order for Benzodiazepine Medication	Order for benzodiazepine medication based on abstraction of medical record	Pre and Post Intervention
Individuals Who Received Benzodiazepine Medication	Administration of benzodiazepine medication based on abstraction of medical record	Pre and Post Intervention
Individuals Who Received Scopolamine	Administration of scopolamine (for death rattle) based on abstraction of medical record	Pre and Post Intervention
Sublingual Administration	Sublingual administration of medication based on abstraction of medical record	Pre and Post Intervention
Individuals With Pastoral Care Visit	Pastoral Care Visit based on abstraction of medical record	Pre and Post Intervention
Individuals With an Advance Directive	Presence of advance directive based on abstraction of medical record	Pre and Post Intervention
Individuals With a Palliative Care Consultation	Palliative Care Consultation based on abstraction of medical record	Pre and Post Intervention

Collaborators and Investigators

• Sponsor: US Department of Veterans Affairs
• Investigators: Principal Investigator: Kathryn L Burgio, PhD MA BA, Birmingham, Alabama VA Medical Center

Publications and helpful links

General Publications

• Williams BR, Woodby LL, Bailey FA, Burgio KL. Identifying and responding to ethical and methodological issues in after-death interviews with next-of-kin. Death Stud. 2008;32(3):197-236. doi: 10.1080/07481180701881297.
• Woodby LL, Williams BR, Wittich AR, Burgio KL. Expanding the notion of researcher distress: the cumulative effects of coding. Qual Health Res. 2011 Jun;21(6):830-8. doi: 10.1177/1049732311402095. Epub 2011 Mar 10.
• Bailey FA, Williams BR, Goode PS, Woodby LL, Redden DT, Johnson TM 2nd, Taylor JW, Burgio KL. Opioid pain medication orders and administration in the last days of life. J Pain Symptom Manage. 2012 Nov;44(5):681-91. doi: 10.1016/j.jpainsymman.2011.11.006. Epub 2012 Jul 4.
• Bailey FA, Allen RS, Williams BR, Goode PS, Granstaff S, Redden DT, Burgio KL. Do-not-resuscitate orders in the last days of life. J Palliat Med. 2012 Jul;15(7):751-9. doi: 10.1089/jpm.2011.0321. Epub 2012 Apr 26.
• Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. J Gen Intern Med. 2020 Feb;35(2):505-513. doi: 10.1007/s11606-019-05538-x. Epub 2019 Dec 2.
• Riggs JS, Woodby LL, Burgio KL, Bailey FA, Williams BR. "Don't get weak in your compassion": bereaved next of kin's suggestions for improving end-of-life care in Veterans Affairs Medical Centers. J Am Geriatr Soc. 2014 Apr;62(4):642-8. doi: 10.1111/jgs.12764. Epub 2014 Mar 21.
• Bailey FA, Williams BR, Woodby LL, Goode PS, Redden DT, Houston TK, Granstaff US, Johnson TM 2nd, Pennypacker LC, Haddock KS, Painter JM, Spencer JM, Hartney T, Burgio KL. Intervention to improve care at life's end in inpatient settings: the BEACON trial. J Gen Intern Med. 2014 Jun;29(6):836-43. doi: 10.1007/s11606-013-2724-6.

Helpful Links

• Growthhouse website MegaSearch, an international clearing house for high quality educational materials related to hospice and palliative care

Study record dates

Study Major Dates

• Study Start: August 1, 2005
• Primary Completion (Actual): March 1, 2011
• Study Completion (Actual): September 1, 2013

Study Registration Dates

• First Submitted: October 4, 2005
• First Submitted That Met QC Criteria: October 4, 2005
• First Posted (Estimate): October 6, 2005

Study Record Updates

• Last Update Posted (Estimate): April 27, 2015
• Last Update Submitted That Met QC Criteria: April 23, 2015
• Last Verified: April 1, 2015

More Information

Terms related to this study

• Keywords: Quality of Health Care; Palliative Care; Inpatients; Hospice Care; Patient Care Planning; Terminal Care; Nursing Care Plans; Professional education; Resuscitation orders; Pastoral Care
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Respiration Disorders; Signs and Symptoms, Respiratory; Dyspnea
• Other Study ID Numbers: IIR 03-126