The end of the journey

12 The end of the journey


discharge from hospital and the experience of death




Introduction


Wherever your medical placement is, your patients will ultimately be discharged home from the service they are currently using. So, if you are placed in a hospital ward or department, the patient will be discharged back to their home and, for some, this could mean a care home or similar environment. Sometimes patients are discharged home on the same day if you are in an investigations unit, or after a few days if you are on a medical ward. In an intermediate care setting or virtual setting (see Ch. 2), there may be a fixed length of time the patient will stay, for example 6 weeks, and then their care would be transferred elsewhere or they would be discharged home. Patients with long-term medical conditions may remain within the service, for example under the care of a medical consultant or clinical nurse specialist visiting out-patients, for the rest of their life.


Given the nature of medical placements, some of your patients will be acutely unwell and may die during their stay in hospital; others with long-term health conditions may be entering the end stages of their illness. Part of their care in a medical placement area will be to receive palliative or end of life care or be prepared for this in another setting such as their own home or a hospice.


This chapter will begin by looking at the normal process of the discharge home of a patient and the role of the nurse in discharge planning. It will then explore the end of life care that a patient may experience and, as a comparison, what can be a traumatic experience for nursing staff and patients’ families – the sudden death of a patient in hospital.



Planning for discharge from hospital


As your patients will not expect or want to stay in hospital any longer than is necessary, it is essential that discharge planning begins on admission. Discharge planning should be an ongoing process throughout a patient’s stay. It requires the multidisciplinary team to work together with the patient and their carer, if appropriate, to identify what will be required for the patient to be discharged home safely and in a timely manner – that is, as soon as they are medically well enough. The Nursing and Midwifery Council (NMC) Standards (2010) contain a number of competencies that are relevant to discharge planning, so should form part of your learning outcomes. They expect the following:



You will understand the roles and responsibilities of other health and social care professionals and seek to work with them collaboratively for the benefit of all people in need of care.


You will work with the person and others to make sure that they are actively involved in decision making in order to maintain their independence and take account of their ongoing intellectual, physical and emotional needs.


You will use verbal, non-verbal and written communication to listen, recognise, interpret and record people’s knowledge and understanding of their needs. You must share information with others while respecting individual rights to confidentiality.


You will work closely with individuals, groups and carers, using a range of skills to carry out comprehensive, systematic and holistic assessments. These must take into account current and previous physical, social, cultural, psychological, spiritual, genetic and environmental factors that may be relevant to the individual and their families.


You will recognise when the complexity of clinical decisions may need specialist knowledge and expertise and then consult or refer accordingly.


You will work effectively across professional and agency boundaries, respecting and making the most of the contributions made by others to achieve integrated person-centred care.


You will work as an independent practitioner as well as part of a team, taking a leadership role in coordinating, delegating and supervising care safely and appropriately while remaining accountable.


The more thorough your assessment on admission, the more you will understand what your patient will need in order to be discharged into a safe environment. An example may be their level of independence with certain activities of daily living. You will need to ensure your patients have reached independence by the time they are discharged or, if it seems likely that this will take a longer time than their stay in hospital, that sufficient provision is made for them to be able to maintain their activities of daily living at home and then rehabilitate further with support in the community.


The majority of discharges will be simple discharges – that is, those patients who are being discharged back to their own homes with simple ongoing needs that do not require any complex planning or delivery (Department of Health (DH) 2004).



Some patients will be discharged to a care home setting. If this is their usual place of residence, it may be necessary for a nurse from the care home to assess the patient before they are discharged, to ensure that the staff in the care home are able to meet any ongoing needs the person has. Care homes are registered to provide different levels of care and it is essential that you are aware of the level of registration your patient’s care home has to determine if their needs can be met there. A ‘care home’ will provide its residents with help with washing and dressing (personal care) and giving medication. A ‘care home with nursing’ has a registered nurse on duty 24 hours a day and will also provide personal care and give medications, but will be able to care for patients who are frailer, physically or mentally.



The Department of Health (2010) has recommended 10 steps to help achieve a safe and timely discharge from hospital (see Box 12.1).



If your patient will require support at home, it will be part of your role as their nurse to ensure they have been adequately assessed by different members of the multidisciplinary team. This will involve identifying any needs they may have, during your ongoing assessment of their needs, and referring appropriately to the physiotherapist, occupational therapist, social worker and other members of the multidisciplinary team as necessary. An awareness of the services available in your local community to support people at home will help here. This should include statutory services provided in people’s own homes and in residential accommodation, for example intermediate care services and services provided by local voluntary agencies. Communication between hospital and community services is essential for a ‘seamless’ approach to care delivery for the patient.




Expected (estimated) dates of discharge


You will find that an expected date of discharge is set early on during your patient’s stay, sometimes even on admission. This is often quite easy to do once a diagnosis has been established. Expected dates of discharge are often based on the length of the therapy required to treat a particular condition and the amount of rehabilitation required to enable your patient to reach their pre-morbid functional level and leave hospital.


Of course, expected dates of discharge are initially based on the best case scenario, so if your patient does not recover as quickly as expected or suffers from any complications which cause a setback in their hospital stay, then their expected date of discharge will be reviewed accordingly.



The expected date of discharge will often be reviewed on the ward round or at a multidisciplinary meeting.



As your patient approaches their expected date of discharge, there will be numerous things you will need to coordinate to ensure they are ready to be discharged as planned.


The checklist in Figure 12.1 includes many of the things that need to be considered and confirmed before your patient is ready to go home. All of these will not necessarily apply to all patients.




By the time your patient reaches their expected date of discharge, all of the items on the checklist should have been confirmed and any community services needed should be ready to start. On the day of discharge, your patient may need to be examined by their doctor to ensure they are well enough to leave hospital. Some wards may operate a nurse-led discharge system, where a senior nurse can assess the patient on the day of discharge to determine if they are ready to be discharged. Figure 12.2 shows some of the things a nurse will be required to check prior to discharging a patient under a nurse-led discharge system.




Preparing to leave hospital


An important aspect of the discharge process is to make sure that your patient is psychologically prepared to leave hospital. For most patients, once they have recovered from their acute illness they will be ready, but for others, especially those with long-term conditions or ongoing rehabilitation needs, they may have anxieties about leaving hospital. Remember that they have been used to having professionals around them 24 hours a day to call on for help, and the prospect of being at home, maybe alone, and having no one close by if they feel unwell can be a frightening prospect. It is for this reason that commencing discharge planning early is so crucial.




If your patients will need to manage ongoing medical problems themselves, then you need to ensure that they understand their condition and the treatment it requires. This may involve administering medication either orally or by injection (e.g. insulin) or monitoring their condition (e.g. peak flow or blood sugar monitoring) and then responding accordingly by adjusting medication or contacting their GP, practice nurse or clinical nurse specialist.


Assisting your patients to self-medicate and to start managing and monitoring their conditions while in hospital is a good way for you to be sure they understand what they need to do and are capable of doing it independently. If you or your patients have any concerns, these can then be addressed before they are discharged. Often, all your patients and their relatives or carers will need is reassurance that they are recovering and what to expect when they get home; also who to contact should they have any problems or feel unwell.





End of life care


As mentioned previously, some patients may not be ending their time in hospital by going home, and will in fact be entering the end stages of their long-term condition and will require end of life care. For some patients, dying in hospital may be their preferred option, but for many, they may wish to die at home or in another organisation such as a hospice. Some of you may have a placement in a hospice, and more about this kind of care can be found in Howard and Chady (2012), another book in this series.


End of life care is an essential part of nursing and you can expect to encounter this experience in all areas you work in, both the hospital and the community.


There has been growing awareness of the need for good end of life care recently, and this has been supported by a number of initiatives and guidance from the Department of Health, most notably the End of Life Care Strategy (DH 2008).



The aim of these initiatives has been to ensure that all patients requiring end of life care receive the same standard of care and to ensure patients are involved as far as possible in planning for the end of their life, including where they would prefer to be when the time comes.



An important hospital and community team that you should make yourself familiar with is the palliative care team. This is a team of specialist nurses and doctors, often supported by therapists and social workers, who are experienced in managing end of life symptoms and helping patients and families come to terms with the fact that they or their loved one is near the end of their life.




What is palliative care?


The World Health Organization (WHO; 2011) defines palliative care as:



Palliative care aims to do the following (WHO 2011):



Palliative care is a process that may last for months or even years and supports anyone with a life-limiting illness, such as cancer, heart failure, dementia, neurological conditions and respiratory failure. Many of the patients you will care for who are in need of palliative care will be in the last few days, weeks or months of their lives. The management of their end of life requires a team approach and should involve the patient and their relatives as much as they are able to be involved. The following members of the multidisciplinary team are likely to be involved:



A number of nationally recognised tools are used to ensure the standard of care provided at the end of life meets the needs of patients and relatives. Some of the ones used in your placement area may include the Liverpool Care Pathway, the Gold Standards Framework and the Preferred Place of Care (The Marie Curie Palliative Care Institute 2010). Ask your mentor if any of these are used in your area.


Feb 25, 2017 | Posted by in NURSING | Comments Off on The end of the journey

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