The end of the journey

12 The end of the journey


discharge from hospital and the experience of death



Chapter aims




• To enable the student to gain an understanding of the discharge process from hospital for the patient


• To enable the student to understand that the end of the journey for a patient might be death


• To understand what end of life care means for the patient and their family


• To explore sudden death and enable the student to reflect on their role when this happens


• To enable the student to identify their learning and development needs in relation to death and dying



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).



image Activity


Discuss with your mentor which patients are likely to be simple discharges and which will be more complex discharges. Identify what role you could play in each type of discharge and the learning outcomes you could meet in doing this.


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 following Website provides a useful glossary of terms and information on the various housing options available for older people:



http://www.housingcare.org/glossary.aspx (accessed July 2011).


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



Box 12.1 The 10 steps to achieve a safe and timely discharge from hospital (DH 2010)




1. Start planning for discharge or transfer before or on admission.


2. Identify whether the patient has simple or complex discharge and transfer planning needs, involving the patient and carer in your decision.


3. Develop a clinical management plan for every patient within 24 hours of admission.


4. Coordinate the discharge or transfer of care process through effective leadership and handover of responsibilities at ward level.


5. Set an expected date of discharge or transfer within 24–48 hours of admission, and discuss with the patient and carer.


6. Review the clinical management plan with the patient each day, take any necessary action and update progress towards the discharge or transfer date.


7. Involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.


8. Plan discharges and transfers to take place over 7 days to deliver continuity of care for the patient.


9. Use a discharge checklist 24–48 hours prior to transfer.


10. Make decisions to discharge and transfer patients each day.


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.



image Activity


Take some time to find out about the services available locally (that is, in your ‘base trust’ environment) to support patients once they have been discharged from hospital. Arrange to speak to the ward social worker and ask about the services available locally, which patients are eligible for them and how they are referred to each service. The physiotherapist will also be a good source of information about the rehabilitation services available in the community, for example community physiotherapy, home rehabilitation services and in-patient intermediate care services.



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.



image Activity


Find out from your mentor when expected dates of discharge are set for the patients in your area. Where are these documented and how often are they reviewed?


Over the course of your placement, can you see a pattern in the length of stay for patients with similar conditions?


Observe your mentor or another registered nurse talking to your patients and their families about their expected date of discharge and, if it is appropriate, see if you can get involved in the discussions.


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



image Activity


Find out from your mentor which days the ward round and multidisciplinary meetings happen and arrange to attend to some of these rounds and meetings to see how the team decides on an expected date of discharge for each patient and arranges discharge plans.


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.


image

Fig 12.1 Discharge checklist. MDT, multidisciplinary team; EDD, estimated/expected date of discharge; TTA, to take away



image Activity


Your placement area is likely to have its own version of a discharge checklist, so ask your mentor where to find it so you can familiarise yourself with it. Try to identify a patient who is getting close to their estimated discharge date and, using your discharge checklist, assess whether all of their discharge needs have been met. If there is a service or item on the checklist that you are not familiar with, ask your mentor about it.


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.


image image

Fig 12.2 Checklist for 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.



image Reflection point


Think of two patients you have looked after, one who was looking forward to getting home and another who may have been more reluctant or anxious about discharge.



1. What do you think influenced their feelings about being discharged home?


2. What support networks did they have at home?


3. How independent were they?


4. What ongoing needs did they have?



image Activity


Check with your mentor if nurse-led discharge operates in your department and familiarise yourself with any guidelines/checklists that are used. Which nursing staff are able to discharge patients? Did they have to undergo specific training or competency assessments in order to carry out nurse-led discharge? What might the benefits be for the patient being discharged by a nurse?


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.



image Activity


With the help of your mentor, identify a patient who will need to manage an aspect of their ongoing health care themselves once they are discharged (e.g. taking their medication, administering their insulin, checking their blood sugar levels). Discuss with your mentor how you can be involved in educating your patient to do this. This may be something you could speak to a clinical nurse specialist about for advice (e.g. diabetes nurse specialist).



The following two articles will be useful to read as they discuss the importance of communication skills in giving information to patients and the many factors affecting a patient’s ability to manage their own care:



Caress AL (2003). Giving information to patients. Nursing Standard 17(43):47–54.


Hughes SA (2004). Promoting self-management and patient independence. Nursing Standard 19(10):47–52.



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 strategy and other resources aimed at helping health professionals to improve the quality of end of life care can be found at the National End of Life Care Programme Website:



http://www.endoflifecareforadults.nhs.uk/ (accessed July 2011).


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.



Take some time to look at the following Website on end of life care. This is aimed at people who may be nearing the end of their life and their carers and explains what they can expect from end of life care and the different places they can expect to receive it:



http://www.nhs.uk/planners/end-of-life-care/pages/end-of-life-care.aspx (accessed July 2011).


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.



image Activity


Ask your mentor about the palliative care team in your placement area and how to contact them. Try to arrange to spend some time with them while you are on placement, or ask to be involved when they are assessing a patient you are caring for.



What is palliative care?


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



an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.


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



• Affirm life and regard dying as a normal process.


• Neither hasten nor postpone death.


• Provide relief from pain and other distressing symptoms.


• Integrate the psychological and spiritual aspects of patient care.


• Offer a support system to help patients live as actively as possible until death.


• Offer a support system to help the family cope during the patient’s illness and their own bereavement.


• Use a team approach to address the needs of patients and their families, including bereavement counselling if indicated.


• Enhance quality of life, and may also positively influence the course of illness.


• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.


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:



• Ward nurses.


• Specialist nurses.


• Consultants and doctors.


• Physiotherapists.


• Occupational therapists.


• Speech and language therapists.


• Chaplains or other religious leaders.


• Social workers.


• Psychologists.


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.



Liverpool Care Pathway


Care pathways are tools that are used to direct care for a particular group of patients or health problems, ensuring care is standardised, evidence-based and patient centred while also providing a method of monitoring the care given for clinical governance purposes (Vanhaecht et al 2011).


The Liverpool Care Pathway (LCP) is used to direct care in the last 2 to 3 days of someone’s life. It provides guidance and prompts on the management of symptoms such as pain, agitation and nausea and also directs the nursing care the person may require. All care given in these last hours is documented in the pathway.



The following link will take you to more information about the LCP and a sample LCP. See also Chapter 2 in Ellershaw and Wilkinson (2011) for information on how the LCP should be used:



http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/documentation-lcp.htm (accessed July 2011).

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

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