Chapter 3: Discharge care and planning
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Discharge planning at the end of life
Evidence‐based approaches
The National Palliative and End of Life Care Partnership ([28]) has set out a framework for end‐of‐life and palliative care based on key ambitions for the dying person which also relate to carers, families and those important to them. This extends to all aspects of care, including care planning, and is very important when a patient is being discharged for end‐of‐life care. The condition of a person nearing the end of life may change rapidly, so it is essential that choices are made, decisions are reached and community services are accessed without delay to ensure a timely and smooth transition of care from hospital to home or hospice. Discharging a patient at the end of life is often complex and multifactorial and requires a multidisciplinary team approach allowing flexibility and responsiveness to the situation. Figure 3.9 shows an example of a checklist that can be used to help structure the process.
Figure 3.9 Checklist for patients being discharged home for urgent palliative care.
Pre‐procedural considerations
It is important in the first instance to contact relevant community teams to highlight the need for a rapid response to any referrals being made. Community nursing, the community palliative care team and, where appropriate, the community matron should be notified at the earliest opportunity. A fast‐track NHS Continuing Healthcare funding application may need to be submitted to access funding for care provision. This process is used to gain immediate access to funding to allow healthcare professionals to arrange urgent care packages, enabling patients to be cared for and to die in their preferred place, whether it is at home, in a nursing home or in a hospice (Thomas [50]).
Equipment
The patient may also require essential equipment to enable them to return home, such as a profiling bed, commode or hoist. These can often be accessed via the local community nursing team and should be ordered at the first available opportunity. Thomas ([50]) found that 25% of discharges were delayed due to problems with the delivery of equipment to patients’ homes. Once care and equipment are in place and discharge is proceeding, a medical review should take place and a discharge summary should be written with a copy provided to the patient, their GP, community nurses and the community palliative care team. Telephone contact with all of the above is essential to ensure they are in receipt of all the information they require to take over the care of the patient in the community and to make sure that home visits are requested.
Assessment and recording tools
The introduction of Electronic Palliative Care Co‐ordination Systems (EPaCCS) has enabled the recording and sharing of people's care preferences and key details about their care at the end of life. Coordinate My Care (which currently only relates to patients within the London area) allows healthcare professionals to record patients’ wishes within an electronic personalized urgent care plan that can be seen by GPs, community teams, emergency and ambulance services; the plan can then guide the care they provide (https://www.coordinatemycare.co.uk). These care plans are accessed repeatedly by the out‐of‐hours and emergency services, which helps to reduce the number of inappropriate hospital admissions in the last year of life. It is hoped that this type of service will be available nationally in the near future.
