1. Confidential: Quality Improvement Material Belle Morte Committee: Seeking to Improve End-of-Life Care at Loyola

2. Confidential: Quality Improvement Material Team Membership Barbara Pudelek RN, MSN, ACNPJudy Mc Hugh RN MSN Beverly Kopala PhD RNLawrence Reuter SJ Caroline Kelly RN, BSN, MSC Marie Shanahan RN Christine Adams RNMarie Coglianese MPS Daniel Dilling MDMarilyn Reinish RN MSW Jacalyn Kareb RN MS CHPNMary Kay Larson MSN, NP Jeanne Sadlik MLSPam Clementi PhD RN Karen Thomas MS RNRita Vercruysse RN, BSN MPH Kathleen Fujiu BSN, MBA Susan Tuzik RN MSN Kathy Supple ANPTheresa Kristopaitis MD Katherine Wasson PhD, MPH Valerie Bednar RN 1

3. Confidential: Quality Improvement Material Belle Morte, which translates to ‘beautiful death,’ is a multidisciplinary committee created to evaluate and reduce restraint use in patients during end-of-life, in response to CMS requirements. The committee was charged to improve practices within the scope of nursing to improve end-of-life care for patients, in and outside the critical care areas. We began by examining current, institutional data on restraint use in patients at or near time of death. This provided a problem-focused trigger to which the University of Iowa Model for Evidence Based Practice was applied. Belle Morte Belle Morte 2 Titler, M.G. et al. (2001) The Iowa Model of Evidence-Based Practice to promote quality care.

4. Confidential: Quality Improvement Material Aim Statement Decrease the use of restraints during the end of life process  Evaluate data on restraint-related deaths in response to CMS requirements.  Evaluate the removal of restraints at EOL if patient will not be harmed.  Review Policy & Procedure on restraints to include discontinuing restraints during the dying process.  Develop educational tools and training programs in providing end-of-life care in response to an Educational Needs Survey.  Create Multidisciplinary Bioethical Rounds to address end-of-life issues.

5. Confidential: Quality Improvement Material Solutions Implemented Solutions Implemented 4  Evaluated data on restraint-related deaths in response to CMS requirement.  Developed a multidisciplinary committee as joint effort of the Nursing Quality and Safety and Nurse Practice Councils to explore end-of-life care and use of restraints at Loyola.  Followed Iowa Model for Evidence-Based Practice to examine current practices at Loyola and current best practices.  Reviewed and internally reported on relevant literature and research.  Identified four areas of need:  Development of staff education and training in end-of-life skills.  To examine potential cost savings by using a Palliative Care Consult Team.  Identification of a Physician Champion to lead consult team.  Development and completion of an on-line EOL needs assessment survey for RN Staff, Social Workers, and Nursing/Medical Students.

6. Confidential: Quality Improvement Material Solutions Implemented 4  Presented Belle Morte Project at the Evidenced-based Practice Day and Shared Governance Day  Authored article on Belle Morte Committee in “Nurse Link”, February, 2009.  Produced and presented ELNEC Core Curriculum two-day course March, 2009.  Held a round-table discussion with Belle Morte members and Palliative Care expert, Dr. Winifred Teuteberg, as to steps to begin multidisciplinary bioethical rounds.  Designed and developed MICU Bioethics Rounds.  Presented proposed policy changes regarding use of restraints in end-of-life care at Restraint Reduction Liaison Committee meeting.

7. Confidential: Quality Improvement Material Results 5 Confidential: Quality Improvement Material

8. Analysis of Data 5  Restraint use during EOL as a process (CMS Restraint Death Reporting) has decreased from 35.4 % in the 1st Q CY 08 to 11% in the 4th Q CY 08.  Restraint use at time of death has decreased from 38.8% in the in the 1st Q CY 08 to 0% in the 4th Q CY 08.

9. Confidential: Quality Improvement Material Next Steps 8  Include guidelines for the use of restraints at EOL within Restraint Policy and procedure and educate staff to new guidelines.  Work with Ethicists and Pastoral Care to assist physicians and nurses in the active process of caring for patients and families at EOL.  Establish Multidisciplinary Bioethics Rounds and present case studies to address challenges in caring for patients and families at EOL.  Continue educational opportunities for healthcare providers in promoting Belle Morte (Beautiful Death), including an E-Learning Module.  Establish a support group for caregivers in dealing with EOL issues affecting their personal and professional lives.