This paper reports on a system of managing admissions and discharges from a specialist palliative day hospice (SPDH) in the south of England. SPDH is a well established component of palliative care provision in the UK, but studies have rarely addressed issues around admission and discharge. Case study methodology was used to evaluate the programme. Interviews were conducted with five patients who had attended the day hospice, taken a break or been discharged and returned; their carer(s); the key worker from the day hospice; and any other health professional who was involved in the patient's care during the admission. Communication issues were found within the team regarding referral and discharge processes, documentation of care, decision making, and information giving. Family members did not feel involved in decision making in relation to the programme. The most significant finding was the emotional and psychological impact on the patients of taking the break. Discharge from SPDH is known to be a difficult and sensitive issue, especially when patients are living with life-limiting illnesses that can change quickly. The patients in this study all had some form of dependency on the service and four of the five would have chosen to continue attending if they could. They experienced deterioration in psychological and physical wellbeing during the period in which they did not attend.
"According to QIPP estimates, reducing hospital admissions could also save £180 m a year.' This would suggest that clinical decision-making is influenced by cost considerations and therefore De Vries et al. (2012) and Eagle and de Vries (2005) suggest that clinical decision-making is indeed shaped by rationing limitations. Greener (2007), therefore, questions the whole notion of an expert, selfdeterministic patient given the constraints in service provision . "
[Show abstract][Hide abstract] ABSTRACT: This paper will examine understandings of autonomy and choice in relation to palliative and end-of-life care and identify implications for nursing practice.
Autonomy in relation to patient-centred care and advocacy has been identified as a key component of palliative and end-of-life care provision internationally. Understandings of autonomy have emerged in an individualised framework, which may be inadequate in supporting palliative and end-of-life care.
A critical discussion paper.
Seminal texts provide a backdrop to how autonomy is understood in the context of palliative care. An overview of literature from 2001 is examined to explore how autonomy and choice are presented in clinical practice.
A model of autonomy based on a 'decision ecology' model may be more applicable to palliative and end-of-life care. Decision ecology aims to situate the individual in a wider social context and acknowledges the relational dimensions involved in supporting choice and autonomy. Such a model recognizes autonomy around wider care decisions but may also highlight the everyday personal aspects of care, which can mean so much to an individual in terms of personal empowerment and dignity.
A 'decision ecology' model that acknowledges the wider social context, individual narratives and emphasises trust between professionals and patients may support decision-making at end of life. Such a model must support autonomy not just at the level of wider decisions around care choice but also at the level of everyday care.
[Show abstract][Hide abstract] ABSTRACT: Objectives: Home discharge after hospital admission to an inpatient palliative care unit (PCU) is a major
challenge. Dysfunction of the autonomic nervous system is commonly observed in patients with advanced
cancer in this setting. The aim of this prospective observational study was to determine whether the measurement of heart rate variability (HRV) by assessing parameters of the autonomic nervous system on a
24-h-ECG at the time of admission to the PCU was correlated with the likelihood of discharge.
Methods: Sixty hospitalized patients with advanced cancer of distinct origin, admitted to a PCU, were
enrolled consecutively. The Karnofsky performance status scale (KPS) and the palliative performance scale
(PPS) were obtained. HRV was measured over one day (20-24 hours) using a portable five-point ECG. The
aim of the study was to compare HRV measurements in patients who could be discharged and those who
died. The association of these variables with home discharge or death at the PCU was calculated.
Results: Discharge was achieved in 45% of patients while 55% of patients died. Median KPS and median
PPS on admission were significantly higher in discharged patients than in those who died (P=0.001). Patients who were discharged tended to have a higher HRV, although the difference was not significant.
Conclusions: KPS and PPS were significant predictors of the likelihood of discharge while HRV did not
[Show abstract][Hide abstract] ABSTRACT: Background
We conducted a wait-list control randomised trial of an outpatient rehabilitation service for people living with and beyond cancer, delivered in a hospice day care unit. We report the results of an economic evaluation undertaken using the trial data.Methods
Forty-one participants were recruited into the study. A within-trial stochastic cost-utility analysis was undertaken using Monte-Carlo simulation. The outcome measure for the economic evaluation was quality adjusted life years (QALYs). Costs were measured from the perspective of the NHS and personal social services. Uncertainty in the observed data was captured through probabilistic sensitivity analysis. Scenario analysis was conducted to explore the effects of changing the way QALYs were estimated and adjusting for baseline difference in the population. We also explore assumptions about the length of treatment benefit being maintained.ResultsThe incremental cost-effectiveness ratio (ICER) for the base-case analysis was £14,231 per QALY. When QALYs were assumed to change linearly over time, this increased to £20,514 per QALY at three months. Adjusting the estimate of QALYs to account for differences in the population at baseline increased the ICER to £94,748 per QALY at three months. Increasing the assumed length of treatment benefit led to reduced ICERs in all scenarios.Conclusions
Although the intervention is likely to be cost-effective in some circumstances, there is considerable uncertainty surrounding the decision to implement the service. Further research, informed by a formal value of information analysis, would reduce this uncertainty.
BMC Health Services Research 11/2014; 14(1):558. DOI:10.1186/s12913-014-0558-5 · 1.71 Impact Factor
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.