Establishing a Palliative Care Unit: The UCSF Comfort Care Suites Example

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Establishing a Palliative Care Unit The UCSF
Comfort Care Suites Example

• Stephen J. McPhee, M.D.
• Julie Koppel, R.N.
• University of California, San Francisco

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Naming the Unit Comfort Care Suites (CCS)

• Name emphasizes primary goals
• Ensuring patient comfort
• Attending to family needs
• Avoids negative connotations for patient/family
  of palliative care
• Avoids confusion with CCU

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Description

• 2 rooms adjacent to one another and a solarium on
  14-Long medicine-oncology ward (swing beds)
• More home-like decor, with living room
• Pull-out couches allow families to stay
  overnight, keep vigil

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Physical Environment

• Sound-proof (intercom removed)
• Commanding views of San Francisco Bay, Mount
  Sutro eucalyptus forest
• Medical equipment available, masked by cabinetry

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Physical Environment (contd)

• Parquet flooring (vinyl)
• Nature motif (to bring outdoors in)
• Décor, art, fountain
• Stereo, CD player, TV, VCR
• Books, magazines, subscriptions
• Display cabinet of spiritual icons

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Planning Process

• Outgrowth of jury-rigged suites
• Committee convened 1998, met every two weeks
• Site visits to three Bay Area inpatient hospices
• In-service training of 14-L nurses by home
  hospice agency
• Rooms allocated, renovated
• Opening reception in March, 1999

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Fund Raising

• Hospital administration (Director of Nursing,
  CEO)
• Hospitals Auxiliary
• Donations
• Staff
• Patients, families

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Palliative Care Consultation Service

• Team
• 14-L nurses
• Attendings (2--6) General medicine,
  hospitalists, geriatrics
• Pharmacist
• Chaplain, CPE interns
• Social workers
• Ethicist

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Palliative Care Consultation Service
(Recommendation Only Model)

• Patient
• Continues on service of referring attending,
  housestaff
• CCS attendings
• Operate as consultants
• Orders
• Written by referring housestaff according to CCS
  protocol

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Admission Criteria

• Patient is terminally ill, no longer pursuing
  curative treatment, and
• Death imminent (days to a week)
• Needs palliative symptom management
• Patient, family and/or team needs assistance with
  or plans to focus on
• Communication issues around death and dying
• Advance directive issues
• Providing comfort and support to the patient
  and family

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CCS Patients

• Patients who the primary service believes are
  appropriate for the Comfort Care Suites
• Patients may be admitted from 14 Long or another
  unit, any intensive care unit, the emergency
  department, or directly from home or an outside
  institution
• Family conference or discussion must occur
• D word (death or dying ) used
• This is broken, and we cannot fix it.

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Protocol Orders

• 1. Admit to room
• 2. Contact CCS consultation team
• 3. Contact chaplain
• 4. CCS diagnosis/reason for transfer
• 5. Other medical diagnoses
• 6. Code status
• 7. Care plan

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Protocol Orders

• 8. Vital signs (optional)
• 9. Call house officer (optional)
• 10. Diet (as tolerated)
• 11. Oral care (as per RN)
• 12. Pain control
• 13. Dyspnea
• 14. Anxiety

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Protocol Orders

• 15. Secretions
• (e.g., atropine ophthalmic)
• 16. Constipation
• 17. Diarrhea
• 18. Nausea and Vomiting
• 19. Insomnia

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Billing for Services

• Billing diagnosis must differ from underlying
  medical diagnosis (e.g., intractable dyspnea
  instead of cystic fibrosis)
• V66.7 code - palliative care code

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Billing for Services

• Time codes - document time spent with patient,
  family, floor/unit time
• Asked to see patient at request of
• Dr. (Attending)
• Review of symptoms cannot be obtained because
• Patient seen, examined, and discussed with Dr.
  (Resident/Attending)

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Questions?

• Resources
• Protocol orders
• von Gunten CF. "Perspectives on Care at the Close
  of Life. Secondary and Tertiary Palliative Care
  in US Hospitals." Journal of the American Medical
  Association, 2002287(7) 875-81.