Transcript RAPID DISCHARGE PLANNING – GETTING A PATIENT HOME

RAPID DISCHARGE PLANNING –
GETTING A PATIENT HOME
Jacqueline O’Brien MSc
CNM2 Palliative Care
Beaumont Hospital
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Discharge planning
“I want to die at home”
Rapid Discharge Planning
Care transition
Carer education and support
FAQ’s from HCP’s
Using Guidelines
Discharge Planning
• Discharge planning starts from the moment of
admission
• Discharge planning is a core element of
hospital-based palliative care consultation
(Benzar et al 2011)
Discharge Planning
• Palliative Care Teams can provide essential support to
patients with life-limiting illnesses and their families
regarding:
• Psychosocial/Spiritual
• Symptom Management
• Prognosis/Goals of Care (Answering Difficult
Questions)
• What happens next? /Planning for the future (Advance
Care Planning)
• Preferred place of death (Rapid Discharge Planning)
“I want to die at home”
• The issue of preferred place of death is
complex
• Patients commonly express the wish to die at
home (Higginson 2000)
• Several factors influence place of death
(Gomes 2006)
• Patients may describe an inclination rather
than a definitive statement of preferred place
of death.
“I want to die at home”
• Practical/Impractical ?!?
• Possible/Impossible ?!?
Need to carry out a
• Realistic evaluation of the feasibility….
• What are the options?
Need to establish:
• What are the patients expectations?
• What are the families expectations?
Remember!
• Every death is unique
• Even when death is expected it is a deeply
emotional experience
• It may be the families first experience of death
- unsure of what to expect; unsure of what to
do
• The family will naturally look for advice and
guidance ; clear information and effective
support.
• The decision making process must lead to a
consensus of the patient, family and multidisciplinary healthcare team that care at home
in now the priority. This patient is going home
to die.
• Need a guide for this discharge home
• Rapid Discharge Planning (RDP)
Rapid Discharge Planning (RDP)
• RDP is a form of integrated discharge planning
that begins when a seriously ill patient
expresses their wish to die at home
• Complex process
• Multiple healthcare professionals in hospital
and community – needs a collaborative
approach
Rapid Discharge Planning (RDP)
• Need to work together to serve the
best interest of the patient and to
support the family
Care transition from Hospital to
Community
How can this be done effectively?
• Effective Communication – patient, family,
MDT within the hospital, MDT in the
Community (GP, PHN, Pharmacy, CPC etc.)
• Clear and Precise Information and
Documentation
Rapid Discharge Guide
…is a model of care to support
healthcare professional to
co-ordinate the rapid discharge of a
patient from hospital to home within
a governance and risk framework
Who’s involved?
Family
Friends
Patient
Community
Services
Hospital
MDT
Hospital Based Team Members
Consultant
& NCHD
Hospital
Specialist
Palliative
Care Team
CNM,
Nursing
& HCA
Hospital
MDT
MSW OT
PT
Chaplaincy
Pharmacy
Community Based Team
Members
GP
PHN
Local
Community
Palliative
Care
Services
Night
Nursing
Service
Ambulance
Providers
Community
Services
Pharmacy
Equipment
Handover
Services
Rapid
Discharge
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Appropriate
Timing of
Discharge
Transport
Carer
Education &
Support
Discharge
Medications
Carer Education & Support
• Medication management
• Patient Comfort
• What to do if the patient becomes distressed
• What to expect as the patient approaches death
• What to do around the time of death
• How to organise the funeral/burial
• Support
Medication management
• What medication is for
• When to give
• How to administer
• Plans re medications e.g. CSCI
pump
Patient Comfort
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Mouth care
Eye care
Pressure area care
Moving
Personal care/hygiene
Mattress/linen
Manage reduced
hydration/dietary needs
What to do if the patient becomes
distressed
• What the family/carer can do …medication/position etc.
• Who to contact
• Explain that if “999” is dialled it is likely to result in admission
to hospital
What to expect as the
patient approaches death
What to do around the time
of death
• May be hours or days at home
before the patient dies
• Weaker
• Sleeps more
• Reduced interest in fluids/diet
• Changes in
breathing/circulation/colour
• Not for ACPR
• Spend time with the patient
• Describe how to recognise
death has occurred
• Death is not usually dramatic
• Contact funeral directors/
spiritual director
• If CSCI pump –take out battery
– do not remove pump
• Turn off heating in room
How to organise the
funeral/burial
Support
• Discuss patient’s preferences if
possible
• Involve appropriate people
• Choose & contact funeral
directors
• Contact religious advisor
• If cremation – body to be
certified prior to removal and
GP complete documentation
• Provide information on who
family can contact if
worried – GP, PHN, CPC,
Hospital
• Advise to pace themselves –
accept offers of help
FAQ’s by HCP’s
( National Rapid Discharge Guidance for Patients who Wish to Die at Home)
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What should I do in the situation where a patient states that they want to be
discharged for end of life care but their family/ carers state that they do not
wish this to happen?
What should I do in the situation where a patient states that they want to be
discharged for end of life care but carers are not available?
What should I do in the situation where a patient states that they want to be
discharged for end of life care but a member of the MDT feels it is not
appropriate?
What should I do in the situation where a patient states that they want to be
discharged for end of life care over a weekend period?
What should I do in the situation where a patient states that they want to be
discharged for end of life care but they live in an upstairs flat and are unable to
climb the stairs?
How can I best prepare carers?
What do I do in the situation where a patient does not have a medical card?
Who do I advise carers to contact in the event of an emergency?
What should I do in the situation where a patient states
that they want to be discharged for end of life care but
their family/ carers state that they do not wish this to
happen?
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Investigate the family’s fears and reasons
• It may be possible to provide reassurance or allay fears
• If unable to support discharge, discuss with patient
What should I do in the situation where a patient states
that they want to be discharged for end
of life care but carers are not available?
• Investigate what services are available in the community to
support discharge
• If unable to support discharge, discuss with patient
What should I do in the situation where a patient states
that they want to be discharged for
end of life care but a member of the MDT feels it is not
appropriate?
• Investigate reasoning
• If unable to support discharge, discuss with patient
What should I do in the situation where a patient states
that they want to be discharged for end of life care over
a weekend period?
• Find out what supports are available and accessible over the
weekend
• Weigh up the benefits and risks of discharging patients at this
time
• Make a decision on whether to support the discharge or not,
that is in the best interests of the patient
• If unable to support discharge, discuss with patient
What should I do in the situation where a patient states
that they want to be discharged for end of life care but
they live in an upstairs flat and are unable to climb the
stairs?
• Liaise with ambulance service to determine feasibility of
transfer
How can I best prepare carers?
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Explore carer expectations around care delivery
Explore carer fears
What to do if the patient is symptomatic
What to do when the patient dies
Involvement/impact on children
Ensure patient goes home with enough medications for the short term and a
prescription for refill
Check that prescribed medications are available in local pharmacy.
If on a syringe driver/pump provide a prescription.
Provide medications/administration equipment/prescription for night nurse to use
Go through medications with carer so that they recognise when to administer and
for what reasons
Ensure there are stat medications available to treat for nausea, pain, secretions,
anxiety
What do I do in the situation where a patient does not
have a medical card?
• In cases where a medical card is required in emergency
circumstances, such as when a patient wishes to be
discharged home to die, an emergency medical card may be
issued
• No means test applies and cards will be issued within 24
hours
• Liaise with Social Work or the individual’s GP in order to
arrange for its provision
• Ensure that the GP is informed of the GMS number if the
Social Worker has made the application prior to discharge
Who do I advise carers to contact in the event of an
emergency?
• Ensure carer is aware of which professionals are available to
support them and how to contact them
• Check who is available to give support within their social circle
BEAUMONT HOSPITAL PALLIATIVE CARE SERVICES
CHECKLIST FOR RAPID DISCHARGE
Please refer patient to the palliative care service before using this list
Confirm discharge date with family, preferably next of kin
Discuss discharge with patient if appropriate
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Medical Team
1. Prescriptions:
If possible scripts to be issued at least 24 hours in advance of discharge
Ensure all relevant regular and PRN drugs prescribed
Make sure all MDA scripts are correctly written (on MDA prescription)
Check if any hi-tech prescriptions are requested eg. OCTREOTIDE LAR
Tell family to bring prescriptions to pharmacy IMMEDIATELY
If patient has a medical card, drugs can be dispensed on foot of a hospital
prescription only if the prescription is presented to the pharmacy on the date
it is written
2.Home Oxygen:
If necessary, organise Home Oxygen
3.Resuscitation Status:
Clarify resuscitation status
Document resuscitation status for the ambulance staff (use Beaumont headed
notepaper)
4.G.P. and Documentation:
Inform G.P. by telephone
Organise discharge letter
Complete Community Palliative Care referral form
Documentation for Night Nurse if applicable (see over page)
Nurses & Ward Staff
1.Transport:
Organise ambulance transfer
2.PHN:
Inform Public Health Nurse of discharge date and request all necessary
equipment (e.g. pressure relieving mattress)
3. Prescriptions:
Ring community pharmacist on day before discharge to make sure all drugs
are available
If community pharmacist perceives any delay with medications being in house
on discharge, contact ward pharmacist who may dispense a short supply
4.Syringe Pump:
Replenish pump prior to leaving ward
New battery to be put into syringe pump
5.Documentation & Equipment for Night Nurse (see over page)
Palliative Care Team
Local Palliative Care Team to be informed of discharge home by Beaumont
Palliative Care Team
Make a request to the Irish Cancer Society for a night nurse (see over page)
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Irish Cancer Society Night Nurse:
A patient who has cancer is entitled to night nursing support from the Irish
Cancer Society but is NOT guaranteed a nurse.
A patient without cancer may have a Night Nurse funded by the Irish Hospice
Foundation. This is organised by the Irish Cancer Society but is also NOT
guaranteed.
Request for night nurse by palliative care team
Nursing transfer letter by ward staff to be given to family for night nurse
Written documentation of drugs and dosages, to be administered to the
patient
if required, signed by a doctor included in Palliative Care Night Nurse
letter
Home Care Team to be advised of name of Night Nurse and contact details by
the hospital palliative care team or ward staff
Equipment to be supplied by ward and given to family:
Gloves X 6 pairs
Aprons X 3
Syringe Pump Equipment
1
6
6
Mediswabs)
pump)
dressings
vials
Small sharps box.
Orange needles
Green needles,
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2
6
2ml syringes
10ml Luer Lock syringes
Alcohol wipes (e.g.
1
Giving set (for subcut.
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Transparent adhesive
4
Water for Injection 10ml
If you have any queries regarding any aspect of this checklist please do not
hesitate to contact any member of the Palliative Care Team:
CNS Coranne Rice (# 880)
CNS Teresa Byrne (# 685)
CNM 2 Jacqueline O’Brien (#644)
Registrar Dr. Helena Myles (#
480)
Or phone the Palliative Care Office at extn: 3339 / 2820
Medical Team
1. Prescriptions:
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If possible scripts to be issued at least 24 hours in advance of discharge
Ensure all relevant regular and PRN drugs prescribed
Make sure all MDA scripts are correctly written (on MDA prescription)
Check if any hi-tech prescriptions are requested eg. OCTREOTIDE LAR
Tell family to bring prescriptions to pharmacy IMMEDIATELY
If patient has a medical card, drugs can be dispensed on foot of a hospital prescription only if the prescription is presented
to the pharmacy on the date it is written
2.Home Oxygen:
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If necessary, organise Home Oxygen
3.Resuscitation Status:
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Clarify resuscitation status
Document resuscitation status for the ambulance staff (use Beaumont headed notepaper)
4.G.P. and Documentation:
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Inform G.P. by telephone
Organise discharge letter
Complete Community Palliative Care referral form
Documentation for Night Nurse if applicable (see over page)
Nurses & Ward Staff
1.Transport:
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Organise ambulance transfer
2.PHN:
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Inform Public Health Nurse of discharge date and request all necessary equipment (e.g. pressure
relieving mattress)
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3. Prescriptions:
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Ring community pharmacist on day before discharge to make sure all drugs are available
If community pharmacist perceives any delay with medications being in house on discharge,
contact ward pharmacist who may dispense a short supply
4.Syringe Pump:
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Replenish pump prior to leaving ward
New battery to be put into syringe pump
5.Documentation & Equipment for Night Nurse (see over page)
Palliative Care Team
• Local Palliative Care Team to be informed of
discharge home by Beaumont Palliative Care Team
• Make a request to the Irish Cancer Society for a night
nurse (see over page)
• Irish Cancer Society Night Nurse:
• Equipment to be supplied by
ward and given to family:
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A patient who has cancer is entitled to night nursing
support from the Irish Cancer Society but is NOT
guaranteed a nurse.
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A patient without cancer may have a Night Nurse funded
by the Irish Hospice Foundation. This is organised by the
Irish Cancer Society but is also NOT guaranteed.
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Request for night nurse by palliative care team
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Nursing transfer letter by ward staff to be given to family
for night nurse
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Written documentation of drugs and dosages, to be
administered to the patient if required, signed by a
doctor included in Palliative Care Night Nurse letter
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Home Care Team to be advised of name of Night Nurse
and contact details by the hospital palliative care team
or ward staff
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Gloves X 6 pairs
Aprons X 3
Syringe Pump Equipment
1
Small sharps box.
6
Orange needles
6
Green needles,
6
2ml syringes
2
10ml Luer Lock
syringes
6
Alcohol wipes
(e.g. Mediswabs)
1
Giving set (for
subcut. pump)
2
Transparent
adhesive dressings
4
Water for
Injection 10ml vials
Remember that in
Getting a Patient Home…
• The issue of preferred place of death is
complex
• Need to work together to serve the best
interest of the patient and to support the
family
• RDP is a form of integrated discharge planning
• Complex process involving multiple healthcare
professionals in hospital and community
• RDP - Needs a collaborative approach
Document of Reference
• “National Rapid Discharge Guidance for
Patients Who Wish to Die at Home”
• Developed by HSE and Palliative Care
• National Clinical Programme for Palliative Care Clinical
Strategy and Programmes Directorate Health Service
Executive
References
• Benzar E., Hansen R.N., Kneitel M.D., Fromme E.K.,
Discharge Planning for Palliative Care Patients: A Qualitative
Analysis (Journal of Palliative Medicine Jan2011;14(1):6569.
• HSE, Code of Practice for Integrated Discharge Planning
• HSE, National Rapid Discharge Guidance For Patients Who
Wish To Die At Home, National Clinical Programme for
Palliative Care Clinical Strategy and Programme Directorate
Health Service Executive (2013)
• Office of the Ombudsman, A Good Death, A reflection on
Ombudsman Complaints about End of Life Care in Irish
Hospitals (2014)