Institution

Royal Melbourne Hospital – Parkville, Victoria, Australia

Background Although population surveys suggest that 60–70% of Australians would prefer to die at home, only 14% of them achieve this. This is comparatively low compared to other developed countries. Home-based palliative care programs increase the chance of patients dying at home through models of care providing multidisciplinary support for a complex range of care needs at the end of life.¹

Aim To support more patients transitioning home for EOLC through the delivery of a specialist palliative care and HITH hybrid model.

Methods The collaborative program included a team of HITH doctors and nurses; palliative care physicians and clinical nurse consultants; and allied health practitioners including an occupational therapist, physiotherapist and social worker. Referral criteria encompass patients admitted to the inpatient palliative care ward at the Royal Melbourne Hospital who express a preference for home-based palliative care and have an available caregiver. Upon admission to the program, patients received daily in-home nursing reviews supplemented by HITH medical consultations via telehealth. Palliative care physicians provided input through coordinated reviews at least weekly during admission, with increased frequency as warranted. Allied health support can be accessed depending on need and after-hours assistance was provided by HITH nursing and medical staff via telephone.

Findings Over the 9 months pilot phase, 10 referrals were made to the program and 4 patients were admitted. The patients who were referred all had a strong desire to return home for EOLC. Reasons for discordance between referrals and admissions to the pathway included rapid change in clinical status, change in discharge destination due to caregiver stress, and availability of alternative services to meet care needs. Of the admitted patients, one fulfilled their wish to die at home, one continued care at home with community supports, while two other patients had planned readmissions to the palliative care unit and managed to spend additional time at home aligned with their wishes.

Lessons Learnt The implementation of this pilot program has strengthened the relationship and collaboration between specialist palliative care and HITH services, which enabled support of patients with complex palliative care needs. There were several challenges including the uptake and integration within the broader service framework, partly due to limited awareness despite educational efforts targeted at inpatient services. Patient-related challenges included unstable symptoms and care needs, as well as rapid clinical fluctuations attributed to underlying disease progression, rendering program admission unfeasible on some occasions. Additional factors encompassed the limited availability and anxiety of caregivers in meeting the high care demands.

Future Directions The program remains ongoing, with a focus on continued education for hospital staff to enhance awareness of its availability. Referral sources have been expanded to include patients from other wards and an adjacent precinct cancer care hospital, and ongoing refinement of referral criteria is underway to optimize program efficacy.

Reference

1. Shepperd S, Gonçalves-Bradley DC, Straus SE, Wee B. Hospital at home: home-based end-of-life care. Cochrane Database Syst Rev. Mar 16 2021;3(3):CD009231.

doi 10.1002/14651858.CD009231.pub3. PMID: 33721912; PMCID: PMC809262