Cet article décrit certains aspects uniques dans les soins des patients de sexe masculin souffrant d'une maladie hématologique, tout au long du processus, depuis l'étape du diagnostic en passant par la phase de traitement jusqu'à la rémission et parfois, malheureusement, jusqu'à la phase de fin de vie. Ce périple peut s'étendre de quelques mois à plusieurs années. Cet article présente aussi le travail effectué auprès de patients de sexe masculin qui suivent une thérapie de groupe au sein du service. Il met en lumière les défis auxquels les hommes sont confrontés, en particulier dans la société israélienne, lorsqu'ils doivent faire face à une maladie potentiellement mortelle.
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OBJECTIVES: This study aimed to evaluate the incidence and causes of hospitalization in the year preceding death of patients with heart failure (HF).
BACKGROUND: Hospitalizations in HF are common, especially in the last period of the lives of patients with HF, but little is known about hospitalization burden and causes during this phase of the disease.
METHODS: From Danish nationwide registries, we identified patients who died in the period 2001-2016 after having experienced HF for at least 1 year, and examined hospitalizations during the last year of life in age- and sex-stratified analyses.
RESULTS: We included 32,157 patients. Median age at time of death was 81 years; 39% were women. A total of 26,561 (84%) patients were hospitalized at least once during the last year of life. The patients experienced a median of 2 (1 to 3) hospitalizations and spent 14 (3 to 31) days in the hospital. Of all hospitalizations (n = 80,362), 9,644 (12%) were due to HF, 14,738 (18%) due to other cardiovascular (CV) causes, and 51,696 (64%) due to non-CV causes (p < 0.001). The frequency of hospitalizations increased toward death, but the domination of non-CV causes remained consistent throughout the year, regardless of age and sex. If we included diagnoses covering renal insufficiency in the definition of HF hospitalizations, non-CV hospitalizations remained dominant (58%).
CONCLUSIONS: During the last year alive, patients with HF were more often hospitalized due to non-CV causes rather than HF. These findings warrant more focus on a multidisciplinary approach toward end-of-life care in patients with HF.
Background: Development of electronic health record (EHR) prediction models to improve palliative care delivery is on the rise, yet the clinical impact of such models has not been evaluated.
Objective: To assess the clinical impact of triggering palliative care using an EHR prediction model.
Design: Pilot prospective before-after study on the general medical wards at an urban academic medical center.
Participants: Adults with a predicted probability of 6-month mortality of = 0.3.
Intervention: Triggered (with opt-out) palliative care consult on hospital day 2.
Main Measures: Frequencies of consults, advance care planning (ACP) documentation, home palliative care and hospice referrals, code status changes, and pre-consult length of stay (LOS).
Key Results: The control and intervention periods included 8 weeks each and 138 admissions and 134 admissions, respectively. Characteristics between the groups were similar, with a mean (standard deviation) risk of 6-month mortality of 0.5 (0.2). Seventy-seven (57%) triggered consults were accepted by the primary team and 8 consults were requested per usual care during the intervention period. Compared to historical controls, consultation increased by 74% (22 [16%] vs 85 [63%], P < .001), median (interquartile range) pre-consult LOS decreased by 1.4 days (2.6 [1.1, 6.2] vs 1.2 [0.8, 2.7], P = .02), ACP documentation increased by 38% (23 [17%] vs 37 [28%], P = .03), and home palliative care referrals increased by 61% (9 [7%] vs 23 [17%], P = .01). There were no differences between the control and intervention groups in hospice referrals (14  vs 22 , P = .13), code status changes (42  vs 39 ; P = .81), or consult requests for lower risk (< 0.3) patients (48/1004  vs 33/798 ; P = .48).
Conclusions: Targeting hospital-based palliative care using an EHR mortality prediction model is a clinically promising approach to improve the quality of care among seriously ill medical patients. More evidence is needed to determine the generalizability of this approach and its impact on patient- and caregiver-reported outcomes.
INTRODUCTION: Metastatic lung cancer is an incurable disease which results in a high burden of symptoms, a poor quality of life and an expected prognosis of less than 1 year after diagnosis. Treatment shortly before death may result in potential burdensome and inappropriate hospital admissions and hospital deaths. Dying at home is, at a population level, considered a quality for good end-of-life care.
AIM: We examined what percentage of patients with metastatic lung cancer died inside the hospital and if hospital death, or other characteristics of the patient, oncologist or healthcare, were associated with treatment in the last month of life.
METHODS: This retrospective cohort study evaluated the medical records of 1322 patients with metastatic lung cancer who received care at one of 10 hospitals across the Netherlands and died between 1-6-2013 and 31-7-2015. Demographic and clinical characteristics were obtained from the medical records.
RESULTS: In total, 18% of the patients died during a hospital admission. This percentage was higher for patients who received chemotherapy (42%) or targeted therapy with tyrosine kinase inhibitors (25%) in the last month of life. Patients younger than 60 years of age, patients who received chemotherapy in the last month of life and patients in whom TKIs were started in the last month of life were more likely to die inside the hospital.
DISCUSSION: In the Netherlands, fewer than one in five patients with metastatic lung cancer died in the hospital and in-hospital death was associated with the relatively late use of chemotherapy or targeted therapy. Careful selection of patients for disease-modifying therapy might enhance the opportunity for patients to die at their preferred place.
Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns.
Objective: Describe hospital EOLOA policies and challenges.
Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications.
Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices.
Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.
OBJECTIVES: While palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease. We sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared to patients with cancer.
METHODS: We conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between 1/2013-12/2017. The PCQN dataset includes patient demographics, processes of care, and patient-level clinical outcomes.
RESULTS: The cohort included 44,933 patients, of whom 4,402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9 years vs. 65.2 years, p<0.0001) and had higher in-hospital mortality (28% vs. 16.8%, p<0.0001). Patients with liver disease were more likely to receive PC consultations to address goals of care (81.7% vs. 67.9%, p<0.0001) as opposed to pain management (10.9% vs. 34.9%, p<0.0001). Both groups had similar rates of symptom improvement and change in resuscitation preferences after PC consultation.
CONCLUSION: Hospitalized patients with liver disease were more likely to have a PC referral to address goals of care compared to those with cancer and were more likely to die in the hospital. Despite late PC consultations, patients with liver disease experienced improvement in symptoms and clarification of their goals of care, similar to those with cancer.
Background: Inpatient palliative care consultation services have been shown to have a dramatic impact on the time cancer patients spend in the hospital, which directly affects overall health care charges and expenditures.
Objective: Our study looks at early palliative care consults in patients with a variety of chronic medical conditions as well as cancer.
Design: This is a retrospective case-control study of patients referred to the palliative care department from April 2014 to June 2016.
Setting/Subjects: This study took place at a university-affiliated community-based urban tertiary care hospital. Cases were patients with a referral placed for a palliative care consult <24 hours after registration into the hospital. Controls were chosen on a one-to-one basis from all other patients referred 24 or more hours after registration. Participants were matched on underlying disease, Charlson comorbidity index, and date of referral.
Measurements: Primary outcomes were hospital length of stay and total hospital charges.
Results: The median (interquartile range) length of stay was 4.2 days (2.0–7.2) for cases and 9.7 days (6.0–18.3) for the control group; p < 0.001. Total hospital charges in U.S. dollars for cases and controls was $38,600 ($22,700–$66,900) and $95,300 ($55,200–$192,700), respectively; p < 0.001. Similar differences were seen for cancer and chronic disease cases and controls.
Conclusions: Our study demonstrates a significant association between reduced length of stay and hospital charges when consults for palliative care were initiated within 24 hours of hospital admission regardless of underlying disease.
Background: There is no nationwide data on polypharmacy in palliative care in Japan. In this study, the research committee of the Japanese Society for Pharmaceutical Palliative Care and Sciences conducted an online survey on polypharmacy and inappropriate prescriptions involving its members who worked as hospital pharmacists.
Methods: The online questionnaire included questions about hospital pharmacist interventions for cancer patients who regularly used six or more drugs during a two-month period from October to November 2017.
Results: Of 2618 hospital pharmacists, 359 responded (13.7%). With regard to cancer patients receiving opioids, 40.9 and 22.3% of the respondents replied that percentages of patients prescribed six or more regular medications were "40-69%" and "70-99%," respectively. Regarding patients on polypharmacy, 73.0% of the respondents reported a low or moderate rate of inappropriate prescriptions, with responses such as "long-term administration of irresponsible or aimless medications", "adverse drug reactions," and "duplication of the pharmacological effect". Furthermore, 24.2, 46.8, and 23.4% of respondents replied that the rates of drug reduction due to pharmacist recommendations were "0", "1-39%", and "more than 40%," respectively. Pharmacist interventions decreased the use of inappropriate medications, including antiemetics, gastrointestinal medications, and hypnotic sedatives, and reduced or prevented adverse drug reactions such as extrapyramidal symptoms, delirium, and sleepiness. Similar results were obtained for cancer patients who did not use opioids. However, the rates of cancer patients on polypharmacy and with reduction of inappropriate medications by pharmacist interventions were significantly higher in cancer patients receiving opioids. Finally, recommendations of board-certified pharmacists in palliative pharmacy contributed to a decrease in the use of inappropriate medications in cancer patients on polypharmacy (p = 0.06).
Conclusion: This nationwide survey clarified pharmacist interventions for polypharmacy in palliative care in Japan. Our data showed frequent polypharmacy in cancer patients receiving opioids, and benefits of pharmacist interventions, especially by board-certified pharmacists in palliative pharmacy, for reducing inappropriate medications and improving adverse drug reactions.
OBJECTIVES: To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care.
DESIGN AND SETTING: Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.
SUBJECTS: Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.
MEASUREMENTS AND MAIN RESULTS: We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.
CONCLUSIONS: Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: 'what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?' Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.
Background: Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging.
Objectives: To demonstrate how careful study design can reveal POLST's impact at hospital admission and why analyses of state registry data are unlikely to capture POLST's effects.
Design: Prospective cohort study.
Setting and participants: Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission.
Results: Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10).
Conclusion: Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.
Population-based surveys suggest that up to 70% of Australians wish to receive care at home when faced with advanced terminal illness; however, only 14% achieve this goal. This is a comparatively low rate compared to other developed countries and due to a myriad of factors, including care fragmentation, lack of advance care planning, inadequate symptom control and limited availability of community-based palliative care services.
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Background: Advanced care planning (ACP) is a process that involves thinking about what medical care one would like should individuals be seriously ill and cannot communicate decisions about treatment for themselves. The literature indicates that ACP leads to increased satisfaction from both patients and healthcare professionals. Despite the well-known benefits of ACP, it is still underutilised in Australia.
Methods: The aim of this study is to investigate the effects of normalising ACP in acute and community settings with the use of specially trained normalisation agents. This is a quasi-experimental study, involving 16 sites (8 intervention and 8 control) in two health districts in Australia. A minimum of total 288 participants will be recruited (144 intervention, 144 control). We will train four registered nurses as normalisation agents in the intervention sites, who will promote and facilitate ACP discussions with adult patients with chronic conditions in hospital and community settings. An audit of the prevalence of ACP and Advanced Care Directives (ACDs) will be conducted before and after the 6-month intervention period at the 16 sites to assess the effects of the ACP service delivered by these agents. We will also collect interview and survey data from patients and families who participate, and healthcare professionals who are involved in this service to capture their experiences with ACP.
Discussion: This study will potentially contribute to better patient outcomes with their health care services. Completion of ACDs will allow patients to express their wishes for care and receive the care that they wish for, as well as ease their family from the burden of making difficult decisions. The study will contribute to development of a new best practice model to normalise ACP that is sustainable and transferable in the processes of: 1) initiation of conversation; 2) discussion of important issues; 3) documentation of the wishes; 4) storage of the documented wishes; and 5) access and execution of the documented wishes. The study will generate new evidence on the challenges, strategies and benefits of normalising ACP into practice in acute and community settings.
The purpose of this analysis was to measure the impact of palliative care services on hospital charges in the 5 days prior to death-the most expensive time of a patient's life-and identify hospital service categories and patient financial classes yielding the highest savings from palliative care. The analysis population included UT Southwestern patients admitted to the hospital between October 1, 2013, and September 30, 2016. Palliative care patients were defined as any patient who received at least one completed palliative care order. In order to create an accurate comparison group, a propensity score match was generated to identify patients most likely to have qualified for a palliative care consult. Covariates included in the model were age, sex, race, financial class, and number of comorbidities. Comorbidities were identified using the Elixhauser Comorbidity Index, and all charges were pulled for the 5 days prior to death. Total hospital charges were also reported by hospital service and financial class. Statistical significance was then derived using a gamma distributed log-linked generalized linear model. The final population included in the analysis, post the propensity score match, was composed of mostly white, non-Hispanic males. The majority of the patients had five or fewer comorbidities, and the primary preexisting conditions seen among patients were cardiovascular diseases (36.0%) and cancer (23.4%). The hospital service categories yielding the highest mean savings were pharmacy (mean $2,765; P < .0001) and labs (mean $1,063; P < .0001). Financial classes with the greatest savings were Medicaid and charity/self-pay. Overall, there was a significant difference in charges between those that received a palliative care consult and those that did not. The fact that the highest savings were in pharmacy and laboratory services suggests that unnecessary labs and medications are discontinued in an effort to improve patient care and quality of life while reducing costs during end-of-life care. Palliative care services ease the cost burden of end-of-life services for low-income populations.
OBJECTIVES: Music therapy has been shown to be effective for reducing anxiety and pain in people with a serious illness. Few studies have investigated the feasibility of integrating music therapy into general inpatient care of the seriously ill, including the care of diverse, multiethnic patients. This leaves a deficit in knowledge for intervention planning. This study investigated the feasibility and effectiveness of introducing music therapy for patients on 4 inpatient units in a large urban medical center. Capacitated and incapacitated patients on palliative care, transplantation, medical intensive care, and general medicine units received a single bedside session led by a music therapist.
METHODS: A mixed-methods, pre-post design was used to assess clinical indicators and the acceptability and feasibility of the intervention. Multiple regression modeling was used to evaluate the effect of music therapy on anxiety, pain, pulse, and respiratory rate. Process evaluation data and qualitative analysis of observational data recorded by the music therapists were used to assess the feasibility of providing music therapy on the units and patients' interest, receptivity, and satisfaction.
RESULTS: Music therapy was delivered to 150 patients over a 6-month period. Controlling for gender, age, and session length, regression modeling showed that patients reported reduced anxiety post-session. Music therapy was found to be an accessible and adaptable intervention, with patients expressing high interest, receptivity, and satisfaction.
SIGNIFICANCE OF RESULTS: This study found it feasible and effective to introduce bedside music therapy for seriously ill patients in a large urban medical center. Lessons learned and recommendations for future investigation are discussed.
BACKGROUND: Hospitals are important sites of end-of-life care, particularly for older people. A need has been identified to understand best practice in hospital end-of-life care from the service-user perspective.
AIM: The aim of this study was to identify examples of good care received in the hospital setting during the last 3 months of life for people dying in advanced age from the perspective of bereaved family members.
DESIGN: A social constructionist framework underpinned a qualitative research design. Data were analysed thematically drawing on an appreciative enquiry framework.
SETTING/PARTICIPANTS: Interviews were conducted with 58 bereaved family carers nominated by 52 people aged >80 years participating in a longitudinal study of ageing. Data were analysed for the 21 of 34 cases where family members were 'extremely' or 'very' satisfied with a public hospital admission their older relative experienced in their last 3 months of life.
RESULTS: Participants' accounts of good care aligned with Dewar and Nolan's relation-centred compassionate care model: (1) a relationship based on empathy; (2) effective interactions between patients/families and staff; (3) contextualised knowledge of the patient/family; and (4) patients/families being active participants in care. We extended the model to the bicultural context of Aotearoa, New Zealand.
CONCLUSION: We identify concrete actions that clinicians working in acute hospitals can integrate into their practice to deliver end-of-life care with which families are highly satisfied. Further research is required to support the implementation of the relation-centred compassionate care model within hospitals, with suitable adaptations for local context, and explore the subsequent impact on patients, families and staff.
OBJECTIVE: Qualitatively evaluate the operation of a palliative care service in oncology.
METHODOLOGY: Qualitative study conducted in a service in southern Brazil based on a fourth generation evaluation. Between September 2014 and June 2015, 460 hours of operation were observed, and 45 semi-structured interviews and five negotiation meetings were conducted; data were analyzed using the constant comparative method.
RESULTS: Potential services are: provision of outpatient palliative care, home and inpatient care provided by a multidisciplinary and support team, meeting the patient's biological, psychological, social and spiritual needs. Study limitations: ineffective communication between clinical and surgical oncology and palliative care sectors, lack of specialized training for professionals and in interpersonal relationship issues among team members.
FINAL CONSIDERATION: For palliative care progress in the service, some arrangements are required to enhance integrality of care.
OBJECTIVE: Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related work in social networks and experimental psychology demonstrates that psychological states-such as optimism-can transfer from one person to another.
METHODS: We directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis prior to the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time following the initial conversation with the patient. We followed patient mortality for 6 months.
RESULTS: Patient optimism was associated with clinician overestimation of their survival in a dose-response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither (OR: 2.95; 95% CI: 1.24-7.02). This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count (ORadj : 3.45; 95% CI: 1.24-9.66).
CONCLUSION: Patients' optimism may have some influence over their clinicians' prognostic judgments.
BACKGROUND: High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital.
METHODS: We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care.
RESULTS: In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, p < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, p < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care.
INTERPRETATION: Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.
Although most individuals prefer to die at home, approximately 60% of Americans die in the hospital setting. Nurses are inadequately prepared to provide end-of-life (EOL) care because of cure-focused education. Friends and family of dying patients report poor quality of death largely as a result of inadequate communication from health care professionals about the dying process. The purpose of this project was to improve nursing knowledge and comfort related to EOL care through use of the CARES tool and to improve the EOL experience of families of dying patients in the hospital setting through use of Final Journey. These acronym organized tools were developed based upon the common symptom management needs of the dying including Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, and Self-care. The CARES tool for nurses improved nursing knowledge and comfort related to EOL care and common symptom management needs of the dying and also enhanced nurses' confidence in communicating about the dying process with friends and family. Final Journey, the friends and family version of the CARES tool, reinforced EOL information for friends and family, helped nurses answer difficult questions, and promoted and enhanced communication between health care professionals and friends and family of the dying.