## 8 A hospital palliative care unit

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### A Hospital Palliative Care Unit (HPCU)

This refers to a bedded unit within a hospital – whether general or specialist, secondary or tertiary. It differs from a Hospital Palliative Care Team (HPCT) in having beds whereas the HPCT is entirely advisory. In many hospitals the beds are under the clinical direction of the specialists in the HPCT who use them for patients they have been asked to see in other parts of the hospital, patients who have complex nursing as well as major medical problems, all more easily cared for in the Palliative Care Unit beds. It can, of course, also function when there is no HPCT.

### The benefits of a HPCU

- The senior medical staff are palliative medicine specialists
- The nurses are trained in palliative care and very experienced
- The patient does not need to be moved to a hospital or hospice unfamiliar to them
- The patients can still be visited by doctors and nurses from other units in the hospital
- The patient can usually return to their home ward when the palliation has been successful.
- All clinical records are available in the hospital
- All diagnostic facilities are available in the hospital
- Ideally medical students and junior doctors can follow the patient and his care regimen both in the original unit and through the HPCU – a rich educational experience.

### The downside of a HPCU

- It is often difficult to persuade management that more can be achieved by having a HPCU than by just having a HPCT advising on patients in the wards where they have been treated in the past. As a small unit with only 4-6 beds it is expensive to operate, especially when the throughput is so fast.
- To be effective it needs the best possible nurse: patient ratio (as in all palliative care) but it is unrealistic and unhelpful to suggest what that should be. Senior management will seldom agree to the establishment of a HPCU which costs more than other comparable units in the hospital. A useful guide is to regard / describe the HPCU as a “High Dependency Unit” and staff accordingly. That will be understood by administrators.

- Frequent visits from ‘allied health professionals’ including social work and pastoral care – all adding to the cost of running such a small unit
- It will sometimes be asked by sceptics if having a HPCU will not deskill junior medical and nursing staff who would learn palliative care better in the original unit rather than in a small specialist unit. There is some evidence that this can happen. It places a heavy responsibility ion the staff of the HPCU to demonstrate what they do and how they do it to all who want to visit the unit. Ideally a HPCU should be the base for a HPCT or, at least, the senior members of the Unit can go to advice in other wards.

### Questions that must be asked before planning a HPCU

- Will the small unit accept only from the other wards and units in the hospital or also admit from the community? This is particularly relevant when there is no well-staffed hospice in the community or no Community Palliative Care Service or few GPs willing / able to provide high quality palliative care in the community. This will materially affect the number of beds needed.
- What statistics about the benefits and disadvantages of a HPCU will be needed to persuade managers and planners that such a unit is /.is not needed? Equally sceptical will be clinicians who have yet to be convinced that any other doctors and nurses can provide better palliative care than they are currently doing in their Oncology or Renal Unit.
- What will happen to a patient admitted to the HPCU, now much improved, who cannot be transferred back to his original ward because there are no available free beds? Will he / she have to remain in HPCU or go to an unfamiliar ward?
- When a patient who has been in the HPCU is discharged home to the care of the general practitioner / family physician, which specialist will be responsible for follow-up? Ideally it should be the medical specialist in the HPCU because palliative care will be the focus of care from then on but this will need to be negotiated with other specialists involved. Transfer to the HPCU can easily be perceived as a subterfuge, taking a patient out of the care of another specialist.
- How do you prevent the HPCU getting the reputation of a Gloom and Doom Ward? Experience of HPCUs in different parts of he world have demonstrated that, like all good hospices and palliative care units, they have a very positive atmosphere, much humour, are often much livelier than general wards, and popular places to work for nurses and doctors – all much to the surprise of other staff within the hospital.
- Initially senior nursing and medical management may know so little about intensive palliative care that they will be uneasy having responsibility for the HPCU. This may affect staff support, appraisals, and staffing levels – almost certainly better than elsewhere in the hospital. They will predictably want to keep costs down.

### Do not resuscitate (DNR) policy

If the hospital has a clear policy then it must be followed in the HPCU. If not then one must prepared for the HPCU and presented to senior medical / nursing staff meetings for explanation and approval. There is likely to be vigorous opposition to what many would see as nihilism in the HPCU. (“You can’t just let someone die – it’s our duty to keep them alive by all means known to us.”)

### Auditing a HPCU

The need for clinical and management audit is as great as, if not more than, in any other palliative care service. It should be given the highest priority, its records kept transparent for all to see and question.

### Professional stress in a HPCU

The stress experienced by those working in a HPCU is no greater than in any other palliative care service except in one respect – they are working in a unit within a hospital where there may be little if any understanding of what palliative care is. They will find that what they do is often misunderstood, seen as sentimental and unscientific, but at the same time other nurses and junior doctors in the hospital may envy their job satisfaction in the HPCU.

Staff may be more than usually anxious about what standard of care patients will receive when they leave the HPCU. Nurses in particular may resent the fast through-put of patients in the HPCU, feeling that a longer spell there would have been good for them.

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