Hospital Palliative Care Unit

Guidelines and Suggestions for those Starting a Hospice/Palliative Care Service, 3^rd edition

Derek Doyle, OBE, MD

This refers to a bedded unit within a hospital – whether general or specialist, secondary or tertiary. HPCU admits patients whose conditions requires specialist palliative care. After stabilizing the situation, the patient is discharged or transferred to another care setting, if possible.

It differs from a Hospital Palliative Care Team (HPCT) in having beds whereas the HPCT is entirely advisory. Ideally a HPCU should be the base for a HPCT or, at least, the senior members of the Unit can go to advice in other wards. In many hospitals the beds are under the clinical direction of the specialists in the HPCT who use them for patients they have been asked to see in other parts of the hospital, patients who have complex nursing as well as major medical problems, all more easily cared for in the Palliative Care Unit beds. It can, of course, also function when there is no HPCT.

Advantages of a HPCU

The senior medical staff are palliative medicine specialists
The nurses are trained in palliative care and very experienced
The patient does not need to be moved to a hospital or hospice unfamiliar to them
The patients can still be visited by doctors and nurses from other units in the hospital
The patient can usually return to their home ward when the palliation has been successful
All clinical records are available in the hospital
All diagnostic facilities are available in the hospital
Special environment for care, closer control/monitoring
Ideally medical students and junior doctors can follow the patient and his care regimen both in the original unit and through the HPCU – a rich educational experience.

Disadvantages of a HPCU

It is often difficult to persuade management that more can be achieved by having a HPCU than by just having a HPCT advising on patients in the wards where they have been treated in the past. As a small unit with only 4-6 beds, it is expensive to operate, especially when the throughput is so fast.
To be effective it needs the best possible nurse/patient ratio (as in all palliative care) but it is unrealistic and unhelpful to suggest what that should be. Senior management will seldom agree to the establishment of a HPCU which costs more than other comparable units in the hospital. A useful guide is to regard/describe the HPCU as a 'High Dependency Unit' and staff accordingly. That will be understood by administrators.
Frequent visits from 'allied health professionals' including social work and pastoral care – all adding to the cost of running such a small unit.
Staff may be more than usually anxious about what standard of care patients will receive when they leave the HPCU. Nurses may resent the fast through-put of patients in the HPCU, feeling that a longer spell there would have been good for them.

Questions that must be asked before planning a HPCU

Will the small unit accept only from the other wards and units in the hospital or also admit from the community? This is particularly relevant when there is no well-staffed hospice in the community or no Community Palliative Care Service or few GPs willing/able to provide high quality palliative care in the community. This will materially affect the number of beds needed.
What statistics about the benefits and disadvantages of a HPCU will be needed to persuade managers and planners that such a unit is needed? Equally sceptical will be clinicians who have yet to be convinced that any other doctors and nurses can provide better palliative care than they are currently doing in their Oncology or Renal Unit.
What will happen to a patient admitted to the HPCU, now much improved, who cannot be transferred back to his original ward because there are no available free beds? Will he/she have to remain in HPCU or go to an unfamiliar ward?
When a patient who has been in the HPCU is discharged home to the care of the general practitioner/family physician, which specialist will be responsible for follow-up? Ideally it should be the medical specialist in the HPCU because palliative care will be the focus of care from then on but this will need to be negotiated with other specialists involved. Transfer to the HPCU can easily be perceived as a subterfuge, taking a patient out of the care of another specialist.
Are the community services well enough developed to take over the care of discharged patients? Are there other services with which you can establish links (social services, primary health care, other charities)?
How do you prevent the HPCU getting the reputation of a 'Gloom and Doom Ward'? Experience of HPCUs in different parts of the world have demonstrated that, like all good hospices and palliative care units, they have a positive atmosphere, much humour, are often much livelier than general wards, and popular places to work for nurses and doctors – all much to the surprise of other staff within the hospital.
Initially senior nursing and medical management may know so little about intensive palliative care that they will be uneasy having responsibility for the HPCU. This may affect staff support, appraisals, and staffing levels – almost certainly better than elsewhere in the hospital. They will predictably want to keep costs down.

Do not resuscitate (DNR) policy

If the hospital has a clear policy, then it must be followed in the HPCU. If not, then one must prepare for the HPCU and presented to senior medical/nursing staff meetings for explanation and approval. There is likely to be vigorous opposition to what many would see as nihilism in the HPCU. ("You can’t just let someone die – it’s our duty to keep them alive by all means known to us.")

Auditing a HPCU

The need for clinical and management audit is as great as, if not more than, in any other palliative care service. It should be given the highest priority; its records kept transparent for all to see and question.

Before the launch of the new service

Ensure that all staff of the hospital – junior and senior, nurses and doctors, social workers and pastoral care workers and all physiotherapists, occupational therapists, art and music therapists, clinical pharmacists and clinical psychologists – are sent details about the service, who will benefit from it and how it will operate.
Ensure that notices about the service, giving all that information, are put on as many notice boards as possible, and as a minimum, one in each ward office and doctors’ office.
Ensure that it is announced at Grand Rounds – preferably by the lead clinician of the new service. As the service develops try to arrange for one session to be devoted to an update on the work and progress of the HPCT.
Ensure that the hospital switchboard is fully informed about the service.
Ensure that junior medical staff, and those in charge of their continuing medical education, know about the service because, very often, when things go wrong it is because they were not sure what was expected of them and whom they were meant to contact for guidance.