11 Hospice palliative care day unit

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Hospice / Palliative Day Care Unit

What is meant by Day Care (sometimes termed Day Hospice or Palliative Care Day Unit)?
It is a model of care designed for patients being cared for at home (or in the home of a relative or in a Nursing Home/ Rest Home). It enables them to receive attention to all aspects of their illness and suffering; to receive physiotherapy and occupational / music / art therapy; to meet with others in similar situations to themselves in a friendly social /non-clinical environment

What benefits can Day Care offer?

The patient is enabled to remain at home as long as possible (which is what most say they want) and by attending the Day Unit

It is very possible but not proven that patients attending a Day Unit are able to remain at home longer than would be the case if they had not attended one. There is much anecdotal evidence that relatives feel it is less stressful caring for a patient at home if the patient can, attend a Day Unit perhaps one or twice a week. Again there is anecdotal evidence that patients feel more positive, more able to cope, less depressed when they attend a Day Unit.

How does a Day Unit operate?

The most common model is where patients are brought from their homes in a car or "minibus" (often driven by a volunteer) to the Day Unit at about 10.00 hrs, spend the middle of the day there and taken back home at about 15.00 hrs.
On arrival they are welcomed by an member of staff/ volunteer, join the others attending for a cup of tea / coffee then spend time on creative activities of their choice under the guidance of the therapists, spend some time with the nurse or doctor. Lunch is leisurely, tailored to their needs and energy and often accompanied by a ‘little drink’ if that is what they enjoy. The time after lunch is spent in comfortable chairs, resting, or being entertained by visiting cooks, TV stars, Olympic champions with their medals, local actors, dancers, poets and musicians – most of whom have usually offered their time and services without any thought of payment.

What accommodation is needed for a Day Unit?

If funds and space permit it is useful to have two rooms rather than one large one – one for activities and crafts, the other for socialising. Equipment takes up much space so adequate storage space must be provided either in the unit or nearby. Not essential but very useful is a small cloakroom where patients outdoor clothes can be left, and another small room where staff and volunteers can withdraw.

Where should a Day Care Unit be situated?

The Unit may be part of a hospital / hospice/ palliative care unit OR be in the grounds of a health care facility. It may be run in a church or community hall not otherwise being used during the day. Essential is that there must be easy vehicle access and that it must be convenient for access for the population being served. Long journeys even in comfortable cars, can be tiring for these patients

What staff are needed for a Day Unit?

The volunteers need very careful selection and comprehensive training (see below). They are directly accountable to, and report to, the Coordinator but are ultimately accountable to the Volunteer Services Manager of the hospice / palliative care service / hospital. They act as friends, assisting with handling frail patients, serving meals and assisting with activities under the direction of the Coordinator or therapist. Or no account do they become involved in clinical matters or attempt to offer professional advice, no matter what is their own background.

What "creative activities" are offered in a Day Unit?

The answer depends on whether or not there is an occupational therapist and his/her skills and experience of palliative care; on the physical and financial resources of the unit, and the culture of the community it serves.
All that can be done here is list some of the activities to be found round the world:

Clay modelling
Painting Pottery
Indoor gardening
Carpentry
Stamp collecting / sorting
Computer programming
Rug making
Crossword solving
Origami
Knitting
Dress making
Enamel jewellery
Making greeting cards
Computer games

The important thing is that such activities are what the patient wants to do (and has often had as a long time ambition) and not merely ‘divert ional’ – helping the patient forget their illness and fate. Everything done in a Day Unit is geared to enhancing quality of life, restoring dignity to it and giving patients as sense of being valued and useful.

The use of volunteers in a Day Unit

Usually the volunteers working in a Day Unit have already worked in other clinical areas of the hospital or palliative care service where their sensitivity and calm presence had been noted. Only then are they selected for the Day Unit and undergo further orientation. They are taught the aims of the Unit, the conditions of the patients who will attend the spectrum of suffering they may encounter and how the palliative care nurses and therapists will respond. Above all else they will be taught to be friends and companions to the patients rather than ‘carers’, encouraged to help create the most relaxed, informal atmosphere possible; the type of atmosphere so often described by patients as 'safe'.
For most volunteers their time in the Day Unit will be the closest and most prolonged they will ever have had with people in the final months of life, many of them of similar age to them or their children. At one and the same time as they see some patients psychologically thriving in that atmosphere they will also notice that they are getting frailer and near to death. Over the time they work in the Day Unit they will make many friends all of whom will eventually die, some much sooner than the volunteers had expected. Understanding support as well as sensitive supervision for volunteers is essential.

Can / should a Day Care Unit accept any type of patient?

Yes, but experience in units that have been operating for many years suggests that patients should be accepted on the understanding that their condition and how much they have benefited / might continue to benefit from attending, is reviewed every 12 weeks. They may then have a spell of not attending and then return after a few months if it is thought they might benefit. If this is not done the Unit may find itself with a patient whose condition is not terminal coming to the Unit for years. This helps neither that patient nor the other patients.
Care has to be taken with particularly young patients who may be discouraged if they attend on days when everyone else is elderly, sharing no common interests with them. Seeing such a young terminally ill person can also be extremely distressing to older patients. Ways have to be found to get around this problem.
Some units find it better to have separate days for the sexes with morning activities and afternoon visitors tailored to each group. For example the men might have visiting football players talk to them whilst the ladies might have ballet dancers or a poet reading a new poem.
It does not seem to matter if people with different illnesses are put together – those with cancer mixing easily with those suffering cardiac or neurological problems. Invariably patients discuss with each other what they suffer from, what care they have had and how long they expect to live. In spite of that there is usually an exceedingly happy, positive atmosphere where everyone wants to help another. It follows, however, that there are times of sorrow when one of their number dies at home or has to be admitted to an in-patient unit. If that unit is adjacent to the Day Unit then they can, and usually do, come back to enjoy the Day Unit with old friends. This is one of the great advantages of any Day Unit being part of a hospital/ palliative care complex rather than free-standing.

Why should planners consider starting a Day Unit?

Can a Day Care Unit be financially self-sufficient?

Craft work produces many items that might be sold, the income helping the day unit. That list would include such things as stools, ornaments, enamel brooches, models, artificial flowers, calendars, Christmas cards. Experience shows that people, particularly friends of the Hospice or relatives, are happy to purchase them but the income usually scarcely covers the cost of purchasing the raw materials from which they are made. What is important though is that patients feel they are not only enjoying themselves but being useful and appreciated.

Audit of a Day Care Unit

It is essential to audit a Day Car Unit, for all members of its staff / team to take part and for its records to be accurate and open to scrutiny. Topics that might usefully be audited include:

Conditions of patients Quality of life measurements
Reasons for referral OT activities and usefulness
Length of time attending unit Reception of patients on arrival
Transport of patients The work of the nurse
Views of GPs / family physicians Finances
Value of different activities Food likes and dislikes
Transport service Bowel treatment needed
Work of volunteers The views of community nurses
Views of relatives Record keeping
Time spent with relatives Dietary issues

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