9 Hospital palliative care team

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Hospital Palliative Care Team (HPCT)

There are compelling reasons for delivering palliative care in an acute-care setting and alongside other disciplines.

The hospital, and therefore its Board and Managers, must be able to recognize a benefit for it as an institution by having defined palliative care services as well as benefit to the inpatient population. Those developing hospital PC services should encourage local administrative authorities to accept symptomatic and end-of-life care as a worthwhile investment in their communities as part of an overall plan for their region.

There are 3 ways of delivering PC in the hospital setting

  1. consultation service – Hospital Palliative Care Team
  2. palliative care unit (tertiary or acute) (See separate section in Getting Started)
  3. combination of 1) and 2)

There is no evaluative data to recommend one delivery system over another. Each delivery method should provide continuity of care between home, acute care, palliative care and local hospice and facilitate an integrated seamless programme of services for patients and families from diagnosis to death.

Consultation Service - Hospital Palliative Care Team (HPCT)

A consultation service develops in response to the need for expert palliative care. The personnel for a consultation team can be simply a nurse or physician alone or combined with pharmacist, spiritual care or social worker.  Those planning a consultation service should not be discouraged by lack of numbers at the outset. Special interest and expertise are essential, however.

Patients and families are seen in consultation only and the HPCT does not assume responsibility for providing care, despite the frustrations inherent in the inability to ‘control’ patient care. This is the best model if resources are limited or institutional needs minimal e.g. a small local hospital with no oncology service and for a ‘start-up’ palliative service. Funding is still required and should be arranged before any such service is started.

Very importantly a consultation service allows for teaching and support for others in healthcare (physicians, nurses, therapists) and can influence their care of other patients under their care but not referred for advice from the HPCT(‘ripple’ effect).Once the service is established it is usually found that much time is spent advising on patients who are in the same unit as the one the team has been called to. Patients and families appreciate the extra time and expertise, do better and credibility producesmore referrals.

The HPCT may be the contact point for Community Palliative Care Services if these are available and one team member should lead in this. If this is the case a HPCT can facilitate smooth transfer to hospital from home and visa versa.

Advantages of a Consultation Team (HPCT) over a dedicated Hospital Palliative Care Unit (HPCU) include:

Disadvantages of a Consultative Service (HPCT) include:

For whatever reason you are considering starting a HPCT there are essential preliminary tasks:

Staffing of a HPCT

Even before considering staffing, bear in mind some of the unique problems associated with this type of service and the stress they can produce
Experience shows that it is much more challenging to bring suffering under control in a general ward, even with a HPCT than in a HPCU with its dedicated palliative care staff, so familiar with every aspect of palliative care

Some examples of problems and disappointments associated with a HPCT may illustrate this:

The skills required in a HPCT

The success of a palliative team depends on its members. They have to be salespersons, advocates, persuaders and highly trained, skilled clinicians. Above all else they must be consummate communicators.  Other colleagues may oppose your plan to start a HPCT because of perceived threats to their autonomous care of their patient or their ability to care for palliative patients.

The characteristics that will win over sceptics include:

Doctor and nurse working alone or as a team?

Will this be a ‘doctor only’ or ‘nurse only’ service or a genuine team of doctor, nurse, pharmacist and social worker and pastoral care worker? Bear in mind the steadily increasing workload of all HPCTs, the salary implications, the stresses involved, the range of conditions they will be asked to advise on.

It is possible, and sometimes necessary, to have a nurse-only service but most undesirable. He/she will be isolated, lonely, have to persuade/convince and stand up to opinionated doctors not accustomed to taking advice from a nurse. Such a service is exceedingly stressful and to be avoided if possible.

Doctor(s): How many, as explained elsewhere in Getting Started, depends on whether or not there will be an associated PCU, a Community Palliative Care Service, a Day Palliative Care Unit, educational and research components, and whether the doctor works in another specialty such as oncology. Advanced training in Palliative Medicine is not optional but essential.

Nurse(s): Registered nurses with extensive training (and preferably a diploma/degree) in palliative care nursing.

Social Worker: If, as should be the case, many of the social needs of the patient are already familiar to the unit’s social worker here is less need for a fulltime social worker on the HPCT. Access to one with palliative care experience is however very useful

Therapists: They are not needed on the team if they can be accessed from their departments in the hospital.

Pastoral Care Worker:  Again, invaluable but hopefully can be accessed in the hospital department

Documentation (see separate section in  Getting Started)

Documentation and statistics gathering is easier to establish at the outset of a programme. Data is useful for research, audit and justification. Drug records and administration charts must comply with hospital practice and legal requirements)

Essential startup documentation:

Operational data should include such information as demographics, age, disease, symptoms, referral source, interventions, follow-up plans, and outcomes (using a validated scale). By having adequate statistics you will be able to lobby for further funding and have a basis for research topics. Information about ‘Minimum Data Sets’ software can be obtained from national palliative care organizations and IAHPC

There is no need to develop a palliative care manual. There are many available in print and some may be downloaded from the internet (such as the IAHPC Manual on this website). Having such a resource facilitates standardisation of care on evidence-based principles.

Before the launch of the new Consultation Service

In summary, a HPCT is worth considering when there are not the resources to start and operate a bedded unit. However, It has to be remembered that the members of the HPCT

Future development of the HPCT may include

It is difficult to factor in all of these from start-up but they should be considered as the unit develops expertise which they can share.

Groups contemplating starting such a service are often daunted by the complexity and expertise of services whose personnel they meet at seminars and on websites they visit. Some are tempted to feel it would be less threatening to start a free-standing unit/ hospice, remote from the frenetic, sometimes aggressive atmosphere of a tertiary referral university teaching hospital.  Remember others have been in the same position and it was no easier then than now.  However it was worth it.

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