Can a Checklist Improve End-of-Life Care?

by Timothy L. Gieseke, MD, CMD

I recently had a tragedy occur for one of my patients who was actively dying. I thought I had done everything possible to insure a “good death” and felt the family and facility team were on board with the care plan. However, when the patient appeared in distress in the early morning hours, his nurse (a recent graduate) reviewed his POLST Form of several months prior and noticed that it specified Attempt CPR and Full Intensity treatment. The POLST had not been updated when there was a change of condition or of the goals of care. The physician on call that night did not know anything about the resident. With the on-call doctor’s approval, the patient was understandably transferred to the closest hospital (not the one that knew him). He was intubated, placed in the ICU, and then his spouse was called. She was understandably angry, requested comfort- focused care, and the patient died later that day.

We have thought deeply about what went wrong and how to reduce the risk of this occurring again. We are not alone in this process. Some years ago, Atul Gawande wrote an excellent book, The Checklist Manifesto, which I commend to your review. It’s available free as a download via their website (link above). Checklists have now been adopted by many of our acute hospital surgical colleagues and have been a major patient safety advance.

I searched for a checklist for EOLC and didn’t find one, but did find helpful resources for building one. Within the INTERACT 4.0 tool kit, there is a Comfort Care Interventions tool that has some good ideas, but they lack specificity for dying in California. This tool kit can be found on the INTERACT WEBSITE.

In 2015, the Coalition for Compassionate Care of California updated the CARE Recommendations for improving EOLC in the PA / LTC setting. These excellent recommendations are available free on their website, click here to visit the webpage.

I have now used both of these resources to create a preliminary checklist. This hasn’t been vetted yet, but since something like this doesn’t yet exist, I thought I would share what I have done in the hope that it might stimulate others to “jump into the water” and develop a better tool that helps facilities minimize the chaos and reduce the risk of similar unfortunate outcomes.

Click here for EOLC Checklist