Hospice involvement key to success of inpatient palliative care
Cooperation with hospitals can foster transition into hospice
It wasn’t long ago when hospices looked on suspiciously as hospitals began talking about providing better end-of-life care within their own facilities, with some hospitals even laying the groundwork for palliative care units. Hospice leaders wondered out loud if hospitals were treading on hospice territory. Hospices and trade associations rallied to remind people they have been providing palliative care for more than two decades. To drive that point home, many hospices and associations added "palliative care" to their organization’s name.
It seems, however, suspicion is giving way to partnership. Hospitals are realizing that they don’t have to reinvent end-of-life care. For their part, hospices understand that by sharing their expertise, they can improve the quality of care of patients in hospitals, a population that has been difficult for them to tap into in the past.
"Several years ago, it was a shock to the hospice industry to see the end-of-life care wave that was sweeping across the country as if it were something new, and we had been doing it for more than 20 years," says Mary Labyak, MSSW, LCSW, president and chief executive officer of Hospice of the Florida Suncoast in Largo, FL.
"Since then, there has been a lot of dialogue between hospices and hospitals," Labyak says. "We are at a different point now and we have an opportunity to deal with each other differently."
Last August, Forsyth Medical Center in Winston-Salem, NC, opened an 11-bed acute palliative care unit to serve terminally ill patients who have chosen to stop aggressive, curative treatment. Hospital administrators decided to dedicate a portion of the facility to palliative care, in part because too many of the hospital’s dying patients were on a waiting list for hospice, and most died before getting an opportunity to benefit from hospice care.
Before the opening of the hospital’s inpatient facility, terminally ill patients in need of acute palliative care services had to be spread out among beds in the hospital’s intensive care unit and other areas.
It was ventures such as these that would cause hospice administrators to shiver at the notion of having to compete with a hospital. Treating dying hospital patients in an inpatient palliative care unit could mean those patients would likely not be referred to a hospice’s own inpatient facility or its home care program.
"The hospitals in our area have been very supportive of hospice," says Joann Davis, chief executive officer of the Hospice and Palliative Care Center in Winston-Salem. "They are competitive with one another, but not with us."
But that was never the intention of Forsyth Medical Center’s program, says Sylvia Beane, RN, nurse manager at Forsyth Medical Center. "This new unit gives Forsyth Medical Center an opportunity to identify patients who can benefit most from palliative care services: patients with cancer, patients with chronic degenerative diseases, patients dying in the ICU on ventilators," Beane says.
"Our patients are not looking for a cure for their illnesses," she continues. "Our goal is to help these patients to live life to the fullest up until the last minute of life. The needs of these patients are great. Often the patient and his family feel guilty because they are not fighting anymore. We’ll address not only their physical needs but their emotional and spiritual needs as well."
Hospital officials instead view the palliative care unit as a transitional setting to help move patients from the hospital to the hospice. The inpatient unit is for patients who are no longer seeking aggressive care and treatment for their terminal illnesses but who still need the services of an acute care hospital.
"These patients need a higher level of care than they can receive at home or in a hospice facility, or they are not strong enough to be transferred to a hospice facility," Beane says. "The new unit will also help ease the waiting list at hospice."
Interest in establishing hospital-based palliative care programs is growing as a result of public and professional recognition of the need to improve care of the seriously ill and dying. Few hospital-based programs offer dedicated units like this one. At 11 beds, Forsyth Medical Center’s acute palliative care unit will be one of the largest hospital-based units in the country, says Beane.
In addition to the pride hospital officials exude when talking about their inpatient palliative care unit, they also acknowledge that it could not have been done without the help of the Hospice and Palliative Care Center, which is located just down the road from the hospital. The center provided a lot of the expertise needed to establish policies and procedures for caring for dying patients who no longer want curative care.
Before the hospital and hospice agreed to collaborate on an inpatient care unit, a symbiotic relationship already existed. Both the hospice and the hospital understood the value of sharing expertise. It was common for hospice nurses to be in the hospital providing consultation to hospital staff and teaching ill patients about hospice. The hospice medical director has also been available for consultation.
Hospice shared routine order sets
As both organizations began exploring the creation of a palliative care unit in the hospital in January 2001, one thing became clear early on: The hospital would not have to go through the time-consuming task of developing palliative care procedures and protocols.
"We knew they were the experts," says Beane. "It was a collaboration from the start."
The hospice readily shared its routine order sets, which helped hospital staff develop plans of care for their palliative care patients. This also facilitates a smoother transition into hospice care, because the care can be easily coordinated with care the patient will receive through hospice.
There is no one model for hospice-hospital palliative care ventures. They can range from full partnerships to hospices simply providing clinical consultations, says Labyak. How the two sides work together is a function of the trust and understanding that have been cultivated prior to the decision to establish an inpatient palliative care unit.
But hospitals and hospices that collaborate should adhere to general principles of palliative care programs, Labyak adds. (For a step-by-step approach, see "Steps for creating an in-hospital program," in this issue.) Hospices and hospitals must establish palliative care programs that emphasize the following:
- physical, psychological, social, and spiritual support to help the patient and family adapt to the anticipated decline associated with advanced, progressive, incurable disease;
- a full array of inter-institutional and community resources (hospitals, home care, hospice, long-term care, adult day services) that promote a seamless transition between institutions/settings and services;
- an environment that supports innovation, research, education, and dissemination of best practices and models of care.
The power of cooperation should not be taken lightly or dismissed as sugar-coated rhetoric. Consider that the Forsyth Medical Center and the Hospice and Palliative Care Center began planning the inpatient palliative care center a year ago. In less than a year, the hospital had all its policies and procedures in place and hospital space dedicated, allowing the center to begin treating patients in September.
"This was never about competition," Beane says. "We realized that the care of these patients is different and that it is about living well while you are dying. We knew hospice had the experts. We would have had a unit without hospice help, but I don’t think it would have been as successful, and if we didn’t already have a good working relationship, there would have been a lot of misunderstanding and backpedaling."
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