## 9 Hospital palliative care team

Table of contents

### Hospital Palliative Care Team (HPCT)

There are compelling reasons for delivering palliative care in an acute-care setting and alongside other disciplines.

- Doing so keeps palliative care in the ‘mainstream’ which is good for both other specialists and disciplines who can learn better end-of-life care and symptom management, and for palliative care staff, who, under the watchful eye of their colleagues, are encouraged to use evidence based principles and treatments and to use the expertise of their colleagues.
- Patients benefit by having access to consultation from other specialties, available imaging, radiotherapy, and other useful palliative modalities.
- A culture of trust and respect develops between palliative experts and others, fostering early, appropriate and more numerous referrals. If designated beds are appropriate a centre of excellence and teaching can develop. The in-hospital bedded unit – the PCU – is discussed in a separate section of Getting Started
- Any successful palliative care service should reflect the needs of the community it serves based on a needs assessment, and fit the requirements and resources (including financial) of the institution. The programme must be flexible and able to adapt to changing hospital priorities and patient needs with the goal of sustaining a long-term service.
- Seeing that high quality palliative care can be provided in a busy medical / surgical /gynaecological / oncology ward is a rich educational experience and personal challenge for junior doctors and nurses who may have thought that it was only possible in a hospice.

The hospital, and therefore its Board and Managers, must be able to recognize a benefit for it as an institution by having defined palliative care services as well as benefit to the inpatient population. Those developing hospital PC services should encourage local administrative authorities to accept symptomatic and end-of-life care as a worthwhile investment in their communities as part of an overall plan for their region.

### There are 3 ways of delivering PC in the hospital setting

1. consultation service – Hospital Palliative Care Team
2. palliative care unit (tertiary or acute) (See separate section in Getting Started)
3. combination of 1) and 2)

There is no evaluative data to recommend one delivery system over another. Each delivery method should provide continuity of care between home, acute care, palliative care and local hospice and facilitate an integrated seamless programme of services for patients and families from diagnosis to death.

### Consultation Service - Hospital Palliative Care Team (HPCT)

A consultation service develops in response to the need for expert palliative care. The personnel for a consultation team can be simply a nurse or physician alone or combined with pharmacist, spiritual care or social worker. Those planning a consultation service should not be discouraged by lack of numbers at the outset. Special interest and expertise are essential, however.

Patients and families are seen in consultation only and the HPCT does not assume responsibility for providing care, despite the frustrations inherent in the inability to ‘control’ patient care. This is the best model if resources are limited or institutional needs minimal e.g. a small local hospital with no oncology service and for a ‘start-up’ palliative service. Funding is still required and should be arranged before any such service is started.

Very importantly a consultation service allows for teaching and support for others in healthcare (physicians, nurses, therapists) and can influence their care of other patients under their care but not referred for advice from the HPCT(‘ripple’ effect).Once the service is established it is usually found that much time is spent advising on patients who are in the same unit as the one the team has been called to. Patients and families appreciate the extra time and expertise, do better and credibility producesmore referrals.

The HPCT may be the contact point for Community Palliative Care Services if these are available and one team member should lead in this. If this is the case a HPCT can facilitate smooth transfer to hospital from home and visa versa.

#### Advantages of a Consultation Team (HPCT) over a dedicated Hospital Palliative Care Unit (HPCU) include:

- No need to fight for space, equipment, facilities
- Minimal personnel commitment (no night call, no holiday relief unless readily available)
- Ability to train other disciplines by hands- on end of life care and example
- Use of pre-existing diagnostic and therapeutic resources and other hospital staff
- Use of the hospital pharmacy and its specialist pharmacists

#### Disadvantages of a Consultative Service (HPCT) include:

- the inability to develop team expertise in a dedicated unit such as a palliative care unit
- the inability to control medication administration.
- the difficulty (though not the impossibility) of doing research
- the difficulty of doing formal bedside teaching when the HPCT does not have its “own beds” .
- the consultation services having to rely on the staff and resources of the institution to provide such services as physiotherapy, occupational-, music-, art -therapy and pastoral care.

For whatever reason you are considering starting a HPCT there are essential preliminary tasks:

- Perform a needs assessment to evaluate the wisdom of a palliative team e.g. if your hospital is a Maternity Hospital it makes no sense. However if it is a general hospital with an oncology service and possibly other specialists it makes good sense.
- Enrol nursing, medical, social work, pastoral and other colleagues in a working group to develop a proposal for formal presentation to your institution
- Find a sympathetic administrator / planner who will support your thinking and proposal
- Meet with Hospital Administration and present your idea/proposal/costings
- Get advanced training in palliative care, read and surf the many good palliative sites on the internet if available
- Meet with colleagues in other disciplines, oncology, surgery, medicine to introduce yourself and the concept of palliative care. Their understanding and collaboration is essential
- Meet with pharmacy administration to enrol their support and inform them of the principles, practice and pharmacopoeia of palliative care. You must be sympathetic to there concerns re: increased workload, overtime budget etc.

### Staffing of a HPCT

Even before considering staffing, bear in mind some of the unique problems associated with this type of service and the stress they can produce
Experience shows that it is much more challenging to bring suffering under control in a general ward, even with a HPCT than in a HPCU with its dedicated palliative care staff, so familiar with every aspect of palliative care

Some examples of problems and disappointments associated with a HPCT may illustrate this:

- Unfamiliar with opioids a, ward doctor discontinues them when the patient vomits. It is a day or two later before the HPCT learns of this.
- Trained to fear opioids because of ‘addiction’, ’tolerance’, ’narcosis’ ‘the consultant / specialist forbids their use in his unit ‘
- Nurses are unhappy when the HPCT suggests a meeting with relatives and patient to explain the care regimen and the prognosis.
- The routine of the unit does not make it easy / possible for a family group to remain near a dying patient
- Staff in the unit have no experience of talking to / listening to a dying patient
- Staff have never properly managed ‘death rattle’ and fail to call for help
- A patient develops intestinal obstruction and is immediately put on ‘drip and suck’ and the surgeons summoned
- Junior staff are unclear whether to consult their senior doctor or the physician of the HPCT when a crisis arises.
- Some senior doctors take offence when changes in a regimen are suggested feeling their authority is being undermined.
- Though the HPCT is there to advise it is often used to find a terminal / palliative care bed somewhere.
- Occasionally the HPCT is called in to give ethical advice for patients not in need of palliative care.

### The skills required in a HPCT

The success of a palliative team depends on its members. They have to be salespersons, advocates, persuaders and highly trained, skilled clinicians. Above all else they must be consummate communicators. Other colleagues may oppose your plan to start a HPCT because of perceived threats to their autonomous care of their patient or their ability to care for palliative patients.

The characteristics that will win over sceptics include:

- Good communication skills i.e. follow-up consultations with a phone call or better still personal contact with the referring physician
- Excellent professional skills and use of evidence based treatments
- Improvement in patient and family condition and good ‘outcome’
- Follow-up of patients
- Your sympathetic understanding of their work - its stresses, disappointments and its problems.
- At all times bear in mind that the team is expected to provide skilled compassionate care in the acute hospital, supporting and advising other clinicians, and aiding support of relatives

### Doctor and nurse working alone or as a team?

Will this be a ‘doctor only’ or ‘nurse only’ service or a genuine team of doctor, nurse, pharmacist and social worker and pastoral care worker? Bear in mind the steadily increasing workload of all HPCTs, the salary implications, the stresses involved, the range of conditions they will be asked to advise on.

It is possible, and sometimes necessary, to have a nurse-only service but most undesirable. He/she will be isolated, lonely, have to persuade/convince and stand up to opinionated doctors not accustomed to taking advice from a nurse. Such a service is exceedingly stressful and to be avoided if possible.

Doctor(s): How many, as explained elsewhere in Getting Started, depends on whether or not there will be an associated PCU, a Community Palliative Care Service, a Day Palliative Care Unit, educational and research components, and whether the doctor works in another specialty such as oncology. Advanced training in Palliative Medicine is not optional but essential.

Nurse(s): Registered nurses with extensive training (and preferably a diploma/degree) in palliative care nursing.

Social Worker: If, as should be the case, many of the social needs of the patient are already familiar to the unit’s social worker here is less need for a fulltime social worker on the HPCT. Access to one with palliative care experience is however very useful

Therapists: They are not needed on the team if they can be accessed from their departments in the hospital.

Pastoral Care Worker: Again, invaluable but hopefully can be accessed in the hospital department

### Documentation (see separate section in Getting Started)

Documentation and statistics gathering is easier to establish at the outset of a programme. Data is useful for research, audit and justification. Drug records and administration charts must comply with hospital practice and legal requirements)

Essential startup documentation:

- job descriptions for every member of staff – whole-time or part-time
- referral and acceptance policies and procedures
- explanatory leaflets on how the service will operate, who takes clinical responsibility, and patient and family brochures (see Communications section in Getting Started)
- specimen reports and recommendations letters

Operational data should include such information as demographics, age, disease, symptoms, referral source, interventions, follow-up plans, and outcomes (using a validated scale). By having adequate statistics you will be able to lobby for further funding and have a basis for research topics. Information about ‘Minimum Data Sets’ software can be obtained from national palliative care organizations and IAHPC

There is no need to develop a palliative care manual. There are many available in print and some may be downloaded from the internet (such as the IAHPC Manual on this website). Having such a resource facilitates standardisation of care on evidence-based principles.

### Before the launch of the new Consultation Service

- Ensure that all staff of the hospital – junior and senior, nurses and doctors, social workers and pastoral care workers and all physiotherapists, occupational therapists, art and music therapists, clinical pharmacists and clinical psychologists – are sent details about the service, who will benefit from it and how it will operate.
- Ensure that notices about the service, giving all that information, are put on as many notice boards as possible, and as a minimum, one in each ward office and doctors’ office.
- Ensure that it is announced at Grand Rounds – preferably by the lead clinician of the new service. As the service develops try to arrange for one session to be devoted to an update on the work and progress of the HPCT.
- Ensure that the hospital switchboard is fully informed about the service.
- Ensure that junior medical staff, and those in charge of their continuing medical education, know about the service because, very often, when things go wrong it is because they were not sure what was expected of them and whom they were meant to contact for guidance

In summary, a HPCT is worth considering when there are not the resources to start and operate a bedded unit. However, It has to be remembered that the members of the HPCT

- must be highly experienced in hospital work, and aware of the workings of the hospital where the HPCT will operate
- expert in the palliative care of patients with a wide range of conditions (and not just malignancy),
- possessed of considerable skills in diplomacy, tolerance and understanding of the needs and problems of the clinicians who refer patients to them
- committed to, and happy to contribute to, teaching in almost every unit they are called to

### Future development of the HPCT may include

- The creation of an in-patient bedded unit within the hospital backing up the HPCT
- University affiliation
- Local national and international recognition, website
- Symposia and seminars
- Collaborative research with other PCUs, HPCTs and free-standing units

It is difficult to factor in all of these from start-up but they should be considered as the unit develops expertise which they can share.

Groups contemplating starting such a service are often daunted by the complexity and expertise of services whose personnel they meet at seminars and on websites they visit. Some are tempted to feel it would be less threatening to start a free-standing unit/ hospice, remote from the frenetic, sometimes aggressive atmosphere of a tertiary referral university teaching hospital. Remember others have been in the same position and it was no easier then than now. However it was worth it.

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