Shared care in the home meeting end-of-life needs

A shared care program where people with advanced COPD are seen regularly by respiratory and palliative care teams in their own home has been met with enthusiasm from respiratory physicians and patients and their families.

The program run out of Cabrini Private Hospital in Malvern, Victoria, is a two stage program and was developed by the hospital in recognition that patients with advanced COPD often found it difficult to access end-of-life care.

In the first stage of the program patients are seen by a respiratory nurse at home who looks after and manages their chronic disease.

“It’s still a chronic disease management style so we’re still treating them for chest infections and other complications but the aim is to enable them to have a good quality of life and keep them at home and out of hospital,” respiratory clinical care consultant Lisa O’Driscoll tells the limbic.

The second stage of the programme is when the respiratory team start working together with the palliative care team.

Triggers for patients moving into this stage of care include an increasing symptom burden and or hospitalisations for chest infections, commencement of home oxygen therapy or if patients were perceived to not be likely to be alive in the next 12 months.

Ms O’Driscoll explains that moving a patient from stage 1 to stage 2 of the program is not a difficult thing to do as the respiratory nurse team have had training on how to initiate an end-of-life conversation and have also developed a relationship with their patient.

“Our nurses have built up a rapport with the patient so it’s easier to bring up the idea of a palliative care plan. Patients are also likely to feel more relaxed in their own home and there’s more of a chance to bring up end of life conversation, perhaps over a cup of tea, and ask them how they’re really going,” she says.

Patients in this stage of the program typically see a respiratory nurse every two weeks followed by a member of the palliative care team so that patients are seeing someone in the home on a fortnightly basis.

According to Ms O’Driscoll one upside to the program is that respiratory nurse and palliative care teams both get upskilled in areas they wouldn’t usually cover.

The respiratory team have completed palliative care outcomes collaboration (PCOC) training and palliative care teams get to learn how to care for patients with respiratory diseases who require different management to people with cancer.

Doctor satisfaction with the program has been really high and feedback from patients families has been positive, Ms O’Driscoll says.

“Our patients need palliative care for longer and more support and our shared care program gives them that… it’s also nice for the respiratory healthcare teams that they don’t need to refer patients to palliative care and then never see them again,” she says.

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