Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Franciscan Health System - West
Georganne Trandum, RN, OCN
Director, Improving Care Through the End of Life
6401 Kimball Drive
Gig Harbor, WA 98335

In 1997, a team of Franciscan Health Services (FSH) professionals initiated an end-of-life pilot project entitled "Improving Care Through the End of Life". Funded by The Robert Wood Johnson Foundation as part of a nationwide effort to improve end-of-life care, the project was sponsored by the Institute for Healthcare Improvement (IHI). The overarching goal of the program was to influence current medical practice such that terminally ill persons could make self-determined treatment and life-closure choices consistent with their values. The intent was to achieve the best possible quality of life through relief of suffering, control of symptoms, and maintenance of functional capacity while remaining sensitive to personal, cultural and religious values, goals, beliefs and practices. Project leaders chose to accomplish this goal by identifying patients with life-threatening illnesses early in the process so that referral to appropriate care and related community resources could occur in a timely fashion.

Conceptually and physically, the program is rooted in a primary-care clinic. The clinic reaches out to patients, families and caregivers of identified patients with life-threatening or terminal illness. Primary care physicians are given a list of patients seen in the last two months and asked, "Would you be surprised if any of these patients died in the next year?" Those patients for whom the answer is, "I would not be surprised," are then targeted for this program. A licensed nurse, particularly hired for the end-of-life population, then contacts each patient and family to assess the patient/family/caregiver needs. Collaborating with the physician to create a plan of care, the nurse coordinates numerous supportive services. A trained volunteer calls a set of patients each month and reports the needs of the patients, families and caregivers to the nurse. A chaplain makes home visits to patients with spiritual and psychosocial issues. In sum, this program targets continuity of care and mobilizes existing resources by authorizing a nurse care coordinator to cut through red tape and shepherd each family through the healthcare system.

Patients and families call one phone number to reach the specialty end-of-life nurse. The nurse in turn, triages the needs and communicates the requests to the primary care physician and appropriate orders and/or clinic appointments can be made. Chaplains involved in the project observed a need to address issues of grief and approaching death among this group of patients and their families. They subsequently developed an additional program called, "Let's Talk" for seniors in the community to meet in groups at local senior service centers and talk about these issues, regardless of whether or not they themselves were suffering from life-threatening illness or participated in the original pilot program. The pilot program of FSH has been replicated in three additional Puget Sound clinics in the past year while continuing program development at the pilot clinic. Two of these new sites for the program are primary care clinics in rural areas serving a large Medicare population, the third is an urban hematology/oncology clinic.

[Return to Circle of Life Award Overview]

Post a Comment