Free-standing Inpatient Unit/Hospice

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

Derek Doyle, OBE, MD

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Free-standing Inpatient Unit/Hospice

A 'free-standing' unit is one not within a hospital, be it a general one or a specialist one. It may be in the grounds of a hospital or totally separate from a hospital, miles away in another part of the town or city. Whether it is called a palliative care unit, or a hospice is a decision that must be made by the Trustees establishing it, bearing in mind that the public (except in French speaking countries) still seem to prefer the term 'hospice' whilst health care professionals understandably prefer 'palliative care unit'. In some countries the name (and requirements) of the facilities is regulated.

What makes any palliative care unit or hospice different from a hospital is not its size (although most are small units with 14 - 30 beds), but the holistic, personalized, flexible programme, and the attitude and focused commitment of the staff.

When planning to open/build a free-standing in-patient unit the following questions must be addressed: Why is a free-standing inpatient unit thought to be needed?

There must be an identified need for care in a hospice according to the pattern of death, and the structure of the society. There must be good reasons why the palliative care unit cannot be within a hospital or palliative care be provided by a hospital palliative care team (HPCT).

A well conducted needs assessment is essential to define the target population, the major clinical problems, the existing services, and networks in the community being served. [See Needs Assessment]

If it is a culture where family bonds are strong and families feel that it is their duty there to care for the patients no matter whatever the cost to them, and the patients want to die in their own beds then maybe it is better to have a second thought and ask if a community palliative care team might be more appropriate or a unit for short stay, for 'acute problems' combined with a such a community team. If patients want to remain at home as long as possible but not die there, a unit may be needed solely for end-of-life care' but it will soon be known as a death house.

If it is a community where there are few relatives to care for their loved ones at home, few nursing homes and poorly developed community services then a long-stay unit is the best solution for offering palliative care. It should be noted that even in a hospice/palliative care unit there can develop the problem of 'blocked beds' occupied by patients who might be better at home or in a nursing/care home, but no places are available.

Will it be a demonstration unit?

If you work in areas where palliative care is in the pioneering stage it might be necessary to demonstrate to the authorities the benefits of hospice, the costs associated with it, the impact of care on the patients and the families to convince them to accept the model and to integrate it into the existing health care system. Making the right choice for the model of care is critical.

The building

What if an existing building is offered or becomes available for purchase? Sometimes hospital buildings become available when re-organization takes place, and some existing buildings are found to be redundant. They may be offered for emerging hospice sometimes with the idea of keeping the workplace for staff who would otherwise be made redundant. Think of all the implications when accepting such an offer. It might not be the best decision for all concerned.

If it is a hospital building offered to set up a 'not-for-profit' unit would the hospice be obliged to forego its high staff/patient ratio, or accept hospital staff without any palliative care training into its interdisciplinary team, or student nurses on rotation through the unit? If yes, then this is not an option and you must find a way to convince your authorities that hospices are well recognized in the world and back up your case with recommendations made by international professional associations or official bodies like European Union, World Health Organization (WHO).

On the other hand, there are some benefits of having the hospice/palliative care unit within the grounds of (but not inside) a general hospital:

Other essential considerations

What other essential things need to be considered at the planning stage?

Target Patients

What type of patients will be admitted to your hospice?

For example, will the unit:

Reading this list is a reminder that strict adherence to the definition of hospice/palliative care is of the utmost importance. It would be well-nigh impossible to care appropriately for many of the above groups in a small palliative care unit but the decision about them must be made before the unit opens.

One must decide if the unit is going to be for:

Once the unit is well known in the community there will soon be a waiting list for admission so apart from establishing in your admission criteria you have to establish the priority criteria for admission. It is useful to have a team responsible for the admissions so as not to put too much pressure on one individual.

Educational programmes

If so, there will need to be a seminar room for teaching, space for a library, storage space for equipment, toilets nearby, access separate from the in-patient unit as well as major staffing and therefore financial implications. [See separate section for fuller discussion]

Disadvantages of a free-standing unit

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