Palliative Care And End-of-life Services In European Health Insurance Programs – “Palliate,” the root word, means to cover, to protect. Palliative care is whole person and family care that is central to all health care. Palliative care is not limited to end-of-life and/or terminal-phase care – it is “available to people living with any illness, at any age and at any stage of an illness” (World Health Organization, 2012) .
Better communication about the different stages, palliative care versus end-of-life care versus terminal care, debunking palliative care myths and championing the benefits of palliative care will help change these misconceptions.
Palliative Care And End-of-life Services In European Health Insurance Programs
Regardless of the prognosis, we at the PHC Hospice Palliative Care Program believe that all people with life-limiting illness should have access to palliative care to get relief from and treatment of their acute pain and or other unwanted symptoms.
End Of Life Care Across The World: A Global Moral Failing
Access to palliative care, either in hospital or in a consultation capacity, is not synonymous with death, nor is it mutually exclusive of other disease-modifying or treatment therapies. Rather, palliative care acts as an adjunct to these treatments, helping to manage patient symptoms, help patients cope with their illness, and improve their overall quality of life.
This video is an introduction to palliative care for the general public and healthcare providers who have no training or experience in palliative care. It reviews the latest evidence supporting the use of palliative care in all serious illnesses. The video aims to dispel myths about palliative care and inform people about how palliative care can be beneficial during a serious illness. The second half of the 40-minute video focuses on patients’ rights around serious illness decision-making and the general structure of decision-making in British Columbia health care. This article explores new and innovative ways of delivering palliative and end-of-life care (EoLC) within the acute hospital setting. Severe financial pressures in the NHS and social care, combined with the increasing clinical complexity of patients, have raised concerns about the quality of EoLC in hospitals. The creation of hospital palliative care units (PCUs) and other improvement initiatives will be described across two major acute hospital associations, which resulted in an “Outstanding” rating by the Care Quality Commission (CQC) for their delivery of end-of- life services.
There has been a desire in the last decade to move the delivery of palliative care from the hospital setting to community and hospice settings; this change is a response to both patient preference and to the varying quality of care experienced by patients who die in hospital.1-3 Although more people live and die at home, about half still die in hospitals. When people die, their focus is less on the place of care and more on the quality of care.4
The national ‘End of Life Care Strategy’ for England identified some issues in the acute hospital environment which can lead to variations in the quality of EoLC care delivered to patients:1
A Caregiver’s Journey
The last decade has seen many developments in hospital-delivered EoLC, but there are still significant concerns about variation in the quality of care.3 Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) and Northumbria Healthcare Foundation Trust (NHFT) are particularly contrasting organisations, RLBUHT is a large teaching association based in an urban centre, while NHFT is an integrated community and hospital association covering one of the largest geographical areas in the country. Despite these differences, they are united in a desire and commitment to deliver the best quality EoLC in all settings. Both trusts have used similar principles to integrate best practice and have shown that exceptional care can be achieved in acute hospital settings.5, 6 Some of these initiatives are described in this article. The goals of both organizations were to increase the quality of palliative care in hospitals, to reduce the number of deaths in acute hospital beds, and ultimately to increase the number of deaths in a palliative care or home setting.
Traditionally, palliative care services have provided a unitary model of care in hospitals. Patients are referred to a hospital palliative care team for advice and input, but remain under the care and responsibility of the referring clinician. Hospital palliative care teams typically provide one-off interventions for most patients or ongoing counseling for more complex individuals. If the intensity of input from palliative care increases or there is a need for a palliative care bed, patients are referred to a hospice, usually in another location and often in another organization. The aims and priorities of a hospice and acute trust are different, which can sometimes lead to tensions in delivering an integrated model. Two key elements of the palliative hospital model are discussed here: the specialist palliative care team and the creation of hospital palliative care units (PCUs). Both elements are intertwined to ensure that patients are managed in the most appropriate setting and receive palliative care, regardless of where they are physically based.
Both organizations have visible and welcoming hospital specialist palliative teams. They provide specialist trust-wide expertise on a daily basis to support all specialties, in addition to supporting patients on an individual basis. They are particularly visible in high intensity areas such as critical care, the emergency department and other inpatient areas where the team focuses on meeting patient needs and assisting with hospital flow. This work is supported by a full training program and multi-professional meetings which link with other key services.
Accurate triaging of patients is essential and enables the team to identify patients who would benefit most from a palliative care bed compared to those who need to stay in the acute setting or those who can go home. In hospital settings, patients often deteriorate rapidly due to delayed recognition, treatment failure and withdrawal, or unexpected acute complications. Quick decisions need to be made about their care in the last days of life, especially around their place of care. Both services have developed rapid discharge processes to address this (see Box 1).
Palliative Care In Acute Hospitals
A middle-aged woman rapidly deteriorated in hospital and actively died. She and her husband wanted her to die at home. The quick discharge process was followed and everything was in place to get her home that day. The ambulance was called to another emergency, leading to a concern that the patient may die before she got home. Her husband decided to drive her. The palliative care nurse went in the car with the patient, settled her in the bed, got the appropriate medication at home and left the care to the district nurses when they arrived. The local nursing team and GP then managed her end-of-life care at home. Having the flexibility to work across settings improves care across transition points, thereby reducing delays that can be a barrier to achieving people’s aspirations.
The RLBUHT Academic Hospital Specialist Palliative Care Team (AHSPCT) is a multi-professional team providing care for all specialties 7 days a week. It consists of nurses, consultants and allied health professionals. It also includes chaplaincy, bereavement services, specialty pharmacies, volunteer services and complementary therapies. The team has a ‘rapid discharge pathway’ which supports co-ordinated care so that, where possible, patients can be discharged home in the last hours/days of life if this is what the patient wishes.
In the NHFT, a similar multi-professional team of nurses, consultants, social workers, pharmacists and chaplains make up the hospital specialist palliative team. Patients who are known everywhere in the palliative care system trigger a ‘recurring admission patient alert’ (RAPA) when contacting the accident and emergency department. This triggers a response from the palliative care team within an hour. Together with integrated electronic clinical records, this allows complex management plans to continue. Other patients are collected through referrals. The team has been restructured to provide different levels of nursing input for different situations; specialist nurses focus on the more complex specialty-specific problems, while palliative care nurses support ward staff with hands-on EoLC and help coordinate quick or complex discharges home. The integrated service allows them to work across settings to follow people home and hand over to community services. A rapid discharge process has been developed with access to key components including a regional palliative care ambulance. The service will soon run over 7 days.
In some parts of the world, hospital palliative care units (PCUs) are common, where inpatient palliative care services have developed as part of their national health systems, compared to the UK, where NHS and voluntary palliative care services are separate. There are a number of potential drivers for setting up a hospital PCU. Patients in hospital develop complex palliative and EoLC needs requiring an intensity of palliative care that would challenge the usual capabilities and resources of a hospital specialist palliative care team. Patients may have acute needs alongside their palliative needs, which are better managed by palliative care with input from other teams. Patients requiring palliative care in a hospital are most likely to have their needs treated more quickly and effectively by being directly under the care of a specialist team rather than providing advice to other teams. Finally, the patient’s expectations change, and the transition from acute to palliative care can be handled more easily in one
Hospice, Palliative Care, And Euthanasia Services
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