1. RAPID DISCHARGE PLANNING – GETTING A PATIENT HOME Jacqueline O’Brien MSc CNM2 Palliative Care Beaumont Hospital

2. Discharge planning “I want to die at home” Rapid Discharge Planning Care transition Carer education and support FAQ’s from HCP’s Using Guidelines

3. 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)

4. 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)

5. “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)

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

7. “I want to die at home” Practical/Impractical ?!? Possible/Impossible ?!? Need to carry out a Realistic evaluation of the feasibility…. What are the options?

8. Need to establish: What are the patients expectations? What are the families expectations?

9. Remember! Every death is unique Even when death is expected it is a deeply emotional experience

10. 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.

11. 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)

12. 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

13. Rapid Discharge Planning (RDP) Need to work together to serve the best interest of the patient and to support the family

14. 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

15. 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

16. Who’s involved? Patient Family Hospital MDT Community Services Friends

17. Hospital Based Team Members Hospital MDT Consultant & NCHD CNM, Nursing & HCA MSW OT PT PharmacyChaplaincy Hospital Specialist Palliative Care Team

18. Community Based Team Members Communit y Services GP PHN Ambulance Providers Pharmacy Night Nursing Service Local Community Palliative Care Services

20. Rapid Discharge is Appropriate EquipmentServices Discharge Medications Carer Education & Support Transport Timing of Discharge Handover

21. 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

22. 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

23. 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

24. 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

25. How to organise the funeral/burial 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 Support Provide information on who family can contact if worried – GP, PHN, CPC, Hospital Advise to pace themselves – accept offers of help

26. FAQ’s by HCP’s ( 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?

27. 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 family’s fears and reasons It may be possible to provide reassurance or allay fears If unable to support discharge, discuss with patient

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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 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) 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 1Small sharps box. 6 Orange needles 6Green needles, 62ml syringes 210ml Luer Lock syringes 6 Alcohol wipes (e.g. Mediswabs) 1Giving set (for subcut. pump) 2Transparent adhesive dressings 4Water for Injection 10ml vials 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

36. 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)

37. 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)

38. 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)

39. 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 1Small sharps box. 6 Orange needles 6Green needles, 62ml syringes 210ml Luer Lock syringes 6 Alcohol wipes (e.g. Mediswabs) 1Giving set (for subcut. pump) 2Transparent adhesive dressings 4Water for Injection 10ml vials

40. 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

41. 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

42. 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):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)