Guidelines and Suggestions for those Starting a Hospice/Palliative Care Service, 3rd edition
Derek Doyle, OBE, MD
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Hospital Palliative Care Team
Hospital Palliative Care Team (HPCT) –or 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.
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 produces more 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 vice versa.
Advantages HPCT over a dedicated HPCU
- No need to fight for space, equipment, facilities
- Minimal personnel commitment (no night call, no holiday relief unless readily available)
- Ability to train other disciplines by hands- on end of life care and example
- Use of pre-existing diagnostic and therapeutic resources and other hospital staff
- Use of the hospital pharmacy and its specialist pharmacists
Disadvantages of a HPCT
- the inability to develop team expertise in a dedicated unit such as a palliative care unit
- the inability to control medication administration
- the difficulty (though not the impossibility) of doing research
- the difficulty of doing formal bedside teaching when the HPCT does not have its 'own beds'
- the consultation services having to rely on the staff and resources of the institution to provide such services as physiotherapy, occupational-, music-, art -therapy and pastoral care
- 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.
Problems and disappointments
Some examples of problems and disappointments associated with a service may illustrate this:
- Unfamiliar with opioids a, ward doctor discontinues them when the patient vomits. It is a day or two later before the service learns of this.
- Trained to fear opioids because of 'addiction', 'tolerance' or 'narcosis', the consultant/specialist forbids their use in his "unit".
- Nurses are unhappy when the service suggests a meeting with relatives and patient to explain the care regimen and the prognosis.
- The routine of the unit does not make it easy/possible for a family group to remain near a dying patient.
- Staff in the unit have no experience of talking to/listening to a dying patient.
- Staff have never effectively managed 'death rattle' and fail to call for help.
- A patient develops intestinal obstruction and is immediately put on 'drip and suck' and the surgeons summoned.
- Junior staff are unclear whether to consult their senior doctor or the doctor of the HPCT when a crisis arises.
- Some senior doctors take offence when changes in a regimen are suggested feeling their authority is being undermined.
- Though the service is there to advise it is often used to find a terminal/palliative care bed somewhere.
- Occasionally the HPCT is called in to give ethical advice for patients not in need of palliative care.
Before planning a HPCT
For whatever reason you are considering starting a HPCT there are essential preliminary tasks:
- Perform a needs assessment to evaluate the wisdom of a palliative team e.g., if your hospital is a Maternity Hospital, it makes no sense. However, if it is a general hospital with an oncology service and possibly other specialists it makes good sense.
- Enrol nursing, medical, social work, pastoral, and other colleagues in a working group to develop a proposal for formal presentation to your institution.
- Find a sympathetic administrator/planner who will support your thinking and proposal.
- Meet with Hospital Administration and present your idea/proposal/costings.
- Get advanced training in palliative care, read, and surf the many good palliative sites on the internet if available.
- Meet with colleagues in other disciplines, oncology, surgery, medicine to introduce yourself and the concept of palliative care. Their understanding and collaboration are essential.
- Meet with pharmacy administration to enrol their support and inform them of the principles, practice, and pharmacopoeia of palliative care. You must be sympathetic to their concerns re: increased workload, overtime budget etc.
In summary, a HPCT is worth considering when there are not the resources to start and operate a bedded unit. However, it must be remembered that the members of the HPCT:
- must be highly experienced in hospital work, and aware of the workings of the hospital where the HPCT will operate.
- expert in the palliative care of patients with a wide range of conditions (and not just malignancy),
- possessed of considerable skills in diplomacy, tolerance and understanding of the needs and problems of the clinicians who refer patients to them.
- committed to, and happy to contribute to, teaching in almost every unit they are called to.
Future development of the HPCT may include:
- The creation of an in-patient bedded unit within the hospital backing up the HPCT.
- University affiliation
- Local national and international recognition, website
- Symposia and seminars
- Collaborative research with other PCUs, HPCTs and free-standing units
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 than now. However, it was worth it.
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