RAPID DISCHARGE PLANNING

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RAPID DISCHARGE PLANNING GETTING A PATIENT HOME

• Jacqueline OBrien 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
• FAQs from HCPs
• Using Guidelines

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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)

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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)

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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)

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• Several factors influence place of death (Gomes
  2006)
• Patients may describe an inclination rather than
  a definitive statement of preferred place of
  death.

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I want to die at home

• Practical/Impractical ?!?
• Possible/Impossible ?!?
• Need to carry out a
• Realistic evaluation of the feasibility.
• What are the options?

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• Need to establish
• What are the patients expectations?
• What are the families expectations?

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Remember!

• Every death is unique
• Even when death is expected it is a deeply
  emotional experience

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• 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.

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• The decision making process must lead to a
  consensus of the patient, family and
  multi-disciplinary 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)

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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

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Rapid Discharge Planning (RDP)

• Need to work together to serve the best interest
  of the patient and to support the family

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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

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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

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Whos involved?
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Hospital Based Team Members
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Community Based Team Members
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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

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• Medication management
• What medication is for
• When to give
• How to administer
• Plans re medications e.g. CSCI pump

• Patient Comfort
• Mouth care
• Eye care
• Pressure area care
• Moving
• Personal care/hygiene
• Mattress/linen
• Manage reduced hydration/dietary needs

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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

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• What to expect as the patient approaches 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

• What to do around the time of death
• 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

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• How to organise the funeral/burial
• Discuss patients 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

• Support
• Provide information on who family can contact if
  worried GP, PHN, CPC, Hospital
• Advise to pace themselves accept offers of help

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FAQs by HCPs( National Rapid Discharge
Guidance for Patients who Wish to Die at Home)

• 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?

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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?

• Investigate the familys fears and reasons
• It may be possible to provide reassurance or
  allay fears
• If unable to support discharge, discuss with
  patient

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What should I do in the situation where a patient
states that they want to be discharged for endof
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

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What should I do in the situation where a
patient states that they want to be discharged
forend of life care but a member of the MDT
feels it is not appropriate?

• Investigate reasoning
• If unable to support discharge, discuss with
  patient

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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 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

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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 they live in an upstairs flat and
are unable to climb the stairs?

• Liaise with ambulance service to determine
  feasibility of transfer

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How can I best prepare carers?

• 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

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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 individuals 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

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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

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BEAUMONT HOSPITAL PALLIATIVE CARE
SERVICESCHECKLIST FOR RAPID DISCHARGE Please
refer patient to the palliative care service
before using this list Confirm discharge date
with family, preferably next of kinDiscuss
discharge with patient if appropriate 

• 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)
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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 Small sharps box.

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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

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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)

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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 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
•  
•  

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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

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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

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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 Jan201114(1)65-69.
• 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)

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