EB004 Critical Appraisal, Evaluation/Summary, and Synthesis of Evidence
Student Name
Walden University
NURS 6052 – Essentials of Evidence-Based Practice
Prof. Name
Date
Full APA Formatted Citation of Selected Articles
Gieniusz, M., Nunes, R., Saha, V., Renson, A., Schubert, F. D., & Carey, J. (2018). Earlier goals of care discussions in hospitalized terminally ill patients, and the quality of end-of-life care: A retrospective study. American Journal of Hospice and Palliative Medicine®, 35(1), 21–27. https://doi.org/10.1177/1049909116682470
Mack, J. W., Cronin, A., Taback, N., Huskamp, H. A., Keating, N. L., Malin, J. L., Earle, C. C., & Weeks, J. C. (2012). End-of-life discussions among patients with advanced cancer: A cohort study. Annals of Internal Medicine, 156(3), 204. https://doi.org/10.1059/0003-4819-156-3-201202070-00008
Schneiter, M. K., Karlekar, M. B., Crispens, M. A., Prescott, L. S., & Brown, A. J. (2019). The earlier the better: The role of palliative care consultation on aggressive end-of-life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients. Supportive Care in Cancer, 27(5), 1927–1934. https://pubmed.ncbi.nlm.nih.gov/30209601/
Starr, L. T., Ulrich, C. M., Corey, K. L., & Meghani, S. H. (2019). Associations among end-of-life discussions, health-care utilization, and costs in persons with advanced cancer: A systematic review. American Journal of Hospice and Palliative Medicine®, 36(10), 913–926. https://doi.org/10.1177/1049909119848148
General Notes and Comments
The Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide provides a valuable framework for assessing the reliability and strength of research evidence. This guide assists healthcare professionals in evaluating the rigor and applicability of research findings to clinical practice. It offers a structured approach that ensures evidence is appraised consistently, fostering sound clinical decision-making.
Evidence Levels Summary Table
| Evidence Level | Description |
|---|---|
| Level I | Randomized controlled trials (RCTs), experimental studies, or systematic reviews of RCTs with/without meta-analysis. |
| Level II | Quasi-experimental research or systematic reviews synthesizing RCTs and quasi-experimental studies. |
| Level III | Nonexperimental research, qualitative studies, or systematic reviews of qualitative/nonexperimental work. |
| Level IV | Authoritative opinions and expert consensus informed by scientific evidence. |
| Level V | Case reports, program evaluations, literature reviews, or expert opinion based on experiential evidence. |
Note on Conceptual Frameworks
Conceptual and theoretical frameworks are critical for structuring research studies. They provide a foundation by ensuring that the study aligns with existing knowledge and methodological standards. While the terms are often used interchangeably, theoretical frameworks usually derive from established theories, offering a formal structure. In contrast, conceptual frameworks map specific variables and relationships within a study’s unique context.
Both frameworks enhance research quality by guiding variable selection, instrument development, and interpretation of findings. They also help identify gaps in current knowledge and justify the significance of the research in the broader field.
Evidence-Based Practice: Early End-of-Life Discussions
Early conversations about end-of-life (EOL) care between healthcare providers and terminally ill patients are increasingly recognized as essential to delivering patient-centered care. These discussions align treatment decisions with patients’ values and preferences, minimize unnecessary aggressive interventions, and promote dignified dying experiences.
Despite advancements in medical technology that can prolong life, research consistently shows many patients with terminal illnesses prefer comfort-oriented care as they approach death. However, many still receive high-intensity care or die in hospitals in ways that may not reflect their wishes.
What does the research say about timing and outcomes of goals-of-care discussions?
Findings from Gieniusz et al. (2018):
Gieniusz and colleagues conducted a retrospective study at a large academic hospital to examine the impact of the timing of goals-of-care discussions (GOCDs) on patient outcomes. The study found:
- Over 90% of terminally ill patients had documented GOCDs.
- Approximately 58.4% of these discussions occurred early during hospitalization, while 33% happened later.
- Each day delay in initiating GOCDs increased the chance of inpatient death by 5%.
These findings suggest that early GOCDs allow for better care planning aligned with patient preferences and reduce the risk of aggressive interventions like ICU transfers or prolonged hospitalization.
How do early EOL discussions affect healthcare utilization and costs?
Findings from Starr et al. (2019):
A systematic review by Starr and colleagues analyzed twenty quantitative studies on EOL discussions. The review found:
- Timely EOL conversations are linked to significant reductions in healthcare costs, particularly in the final month of life.
- Structured communication programs decreased the use of aggressive treatments.
- Early involvement of palliative care enhanced documentation of patient wishes, increased hospice enrollment, and lowered avoidable hospitalizations.
This body of evidence highlights both the economic benefits and ethical importance of early, quality EOL communication.
Why are EOL discussions still not happening early enough?
Findings from Mack et al. (2012):
Mack and colleagues reported that fewer than 40% of patients with advanced cancer had EOL discussions with their healthcare providers. Barriers to early conversations included:
- Clinician discomfort discussing prognosis.
- Limited time during clinical encounters.
- Uncertainty about prognosis.
- Concerns about patient readiness to engage in such discussions.
These challenges emphasize the need for better communication training and institutional support to encourage timely, meaningful EOL conversations.
What role does early palliative care consultation play?
Findings from Schneiter et al. (2019):
Schneiter and colleagues studied gynecologic oncology patients and found:
- Early palliative care consultation reduced aggressive EOL care.
- It increased hospice referrals.
- It improved documentation of advance care planning.
This evidence reinforces that early palliative care is vital for ensuring care aligns with patient goals and preferences, reducing unnecessary interventions, and improving overall quality of life near the end of life.
Summary of Key Benefits of Early End-of-Life Discussions
| Benefits | Description |
|---|---|
| Improved Quality of Life and Satisfaction | Patients experience care that respects their values and preferences. |
| Reduced Unwanted Aggressive Care | Avoidance of ICU stays and interventions unlikely to improve outcomes. |
| Clearer Documentation | More thorough recording of patient wishes, facilitating informed care decisions. |
| Lower Healthcare Utilization & Costs | Reduced hospitalizations and high-cost treatments near the end of life. |
| Increased Hospice Enrollment | Patients access hospice services earlier, promoting comfort-focused care. |
| Ethical and Dignified Care | Care is aligned with patient values, supporting a humane and respectful dying process. |
Implementing structured communication protocols and training clinicians in EOL discussions are essential steps toward achieving these outcomes consistently.
References
Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.
Gieniusz, M., Nunes, R., Saha, V., Renson, A., Schubert, F. D., & Carey, J. (2018). Earlier goals of care discussions in hospitalized terminally ill patients, and the quality of end-of-life care: A retrospective study. American Journal of Hospice and Palliative Medicine®, 35(1), 21–27. https://doi.org/10.1177/1049909116682470
Mack, J. W., Cronin, A., Taback, N., Huskamp, H. A., Keating, N. L., Malin, J. L., Earle, C. C., & Weeks, J. C. (2012). End-of-life discussions among patients with advanced cancer: A cohort study. Annals of Internal Medicine, 156(3), 204. https://doi.org/10.1059/0003-4819-156-3-201202070-00008
EB004 Critical Appraisal, Evaluation/Summary, and Synthesis of Evidence
Schneiter, M. K., Karlekar, M. B., Crispens, M. A., Prescott, L. S., & Brown, A. J. (2019). The earlier the better: The role of palliative care consultation on aggressive end-of-life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients. Supportive Care in Cancer, 27(5), 1927–1934. https://pubmed.ncbi.nlm.nih.gov/30209601/
Starr, L. T., Ulrich, C. M., Corey, K. L., & Meghani, S. H. (2019). Associations among end-of-life discussions, health-care utilization, and costs in persons with advanced cancer: A systematic review. American Journal of Hospice and Palliative Medicine®, 36(10), 913–926. https://doi.org/10.1177/1049909119848148