• Timothy J Keay, Carla Alexander, Karen McNally, Elizabeth Crusse, and Ruth E Eger.
• Department of Family Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. tkeay@umaryland.edu
• J Palliat Med. 2003 Apr 1;6(2):205-13.

ContextNursing homes are the setting for one of five deaths in the United States. Unfortunately these deaths are often accompanied by pain and symptoms of discomfort.ObjectiveTo determine if an educational intervention designed for nursing home physicians improves the quality of dying for nursing home residents.DesignProspective measurement of changes in end-of-life medical care indicators.InterventionHalf-day adult educational outreach program, including audit and feedback, targeted at opinion leaders, and quality improvement suggestions.SettingFive geographically diverse Maryland skilled nursing facilities with a total of 654 beds.ParticipantsThe terminal care delivered by 61 physicians who cared for 203 dying residents in the 5 facilities was reviewed. An intervention was targeted to medical directors and those physicians with the majority of patients. Twelve physicians participated in the educational program.Main Outcome MeasuresChart documentation of recognition of possible death, presence of advance directives, pain control, analgesics used, dyspnea control, control of uncomfortable symptoms during the dying process, documented hygiene, documented bereavement support, and total patient comfort.ResultsThe four nursing facilities that completed the intervention all had significant improvements in end-of-life care outcomes (p < 0.001, chi2). No statistically significant changes were found in any measure in the cohort nursing facility that did not complete the intervention. When we compared residents with hospice services to those without, we found significant increases in documentation of better hygiene, bereavement support, and total patient comfort (p < 0.001, chi2 for each).ConclusionsImportant terminal care outcomes can be significantly improved by targeting key nursing home physicians with an adult educational program that includes audit and feedback, and quality improvement suggestions.

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