The eventual success and effectiveness of a palliative care service
depends very largely on how well it is planned
! the need for a palliative care service is often so great that those eager to
establish it do not always give it the thoughtful planning that is needed
! the planning stage may take much longer than expected, sometimes years
Local factors are most important in planning a palliative care service
! the situation will vary greatly from one country to another and even within
a single country
! IAHPC believes that each developing country should be encouraged and
enabled to develop its own model(s) of palliative care, taking advantage
of the experience and expertise accumulated in developed countries,
and not be expected to copy models more appropriate to affluent
countries
The planning of any palliative care service requires
! a well-conducted needs assessment (subjective assessment of need is
never adequate)
! discussion with local, regional and even national health care planners
(who may not know what palliative care is)
! discussion with all other local groups (statutory and voluntary) providing
palliative care in any form (duplication of services is wasteful and
counterproductive)
! consideration of the model(s) of care which might best meet local needs
! consideration of staffing implications and recruitment issues
! consideration of the educational role of any planned service
! consideration of relations with local hospitals, clinics and diagnostic
facilities
! consideration of the availability of equipment and pharmaceuticals
! consideration of capital investment needs, funding requirements,
reimbursement issues
Needs Assessment
Examples of questions to be asked include
! Patients
o which diseases in a particular community are likely to benefit from
palliative care
o how many potential patients are there
o what is their age distribution
o what is the prevalence of symptoms
o what are thought to be the unmet needs of these patients
o what proportions are dying at home or in hospital
! Priorities
o is the service to provide care or to train family members to care
better
o is the service to provide care or to educate and train local health
care professionals to provide better care
o is the service to provide care or simply assist the doctors and
nurses already managing the patients in the community or hospital
o is the goal to enable more people to remain at home for longer
periods
o is the ultimate goal to enable more people to die at home
! Models of care
o what are the obstacles to good palliation as perceived by health
care workers in the area
o should it provide home care or inpatient care
o should there be a palliative care ward in the local hospital or a freestanding
hospice
o should a hospital service manage the patients or provide advice
and support
o will education be provided and if so which model of care provision
will best facilitate it
! Relationships with other agencies
o what will be the relationship with
" any existing palliative care services
" the local hospital
" the local medical community
o are medications available
o is there access to basic diagnostic facilities
o will medical records in other hospitals be made available
o will fees be charged for the use of any of these facilities
Discussion with Strategic Planners
! those planning a new palliative care service often complain that strategic
planners and health care managers do not want to listen to them and
seem to be ignorant about palliative care
o co-operation with them may not be easy but it is never wasted time
o the planners may need to visit established palliative care services
or be presented with data from other services serving similar
population groups
o the closer the collaboration, the better the eventual service
! the aims of these discussions are
o to inform each other of needs and possible responses
o to prevent duplication of activities and waste of precious resources
o to foster co-operation rather than competition and conflict
! a well planned service, fitting neatly into a local or regional plan, will
enable patients, whether at home or in a hospital, to receive seamless
palliative care
Discussion with Other Providers
Discussions should be held with all other local health care providers who may
be affected by the planned palliative care service
! the local medical community
o the palliative care service needs the co-operation of local doctors,
in order to be able to work with them in providing better care for
patients
o doctors who feel threatened by the service or feel their patients are
being taken over will not be supportive and will not refer patients
who might benefit from palliative care
o it is best to assume that even though some doctors may not know
much about palliative care, they have their patients’ best interests
at heart and want to learn how to better care for them
! the local hospital
o the relationship with the local hospital must be clearly defined to
foster co-operation and to avoid any antagonism
o will palliative care doctors be permitted to see patients in the
hospital?
o will the hospital’s diagnostic facilities be available for palliative care
patients?
o will drugs be available from the hospital pharmacy?
o if hospital patients are transferred to palliative care, will their
records come with them?
! other palliative care services
o to avoid unhealthy competition between palliative care providers
" competition usually wastes precious resources and may
deprive some patients of the care they need and deserve
" competing services can produce confusion in the minds of
the public and the local health care professionals
o each provider to define what service they can offer and then, in
discussion with other providers, decide who does what
" catchment areas can be defined
" agreement can be reached on the types of patients accepted
by each service (e.g. non-malignant disease, AIDS, etc)
o to foster co-operation in
" the use of specialized services e.g. lymphoedema treatment
" education and training
! the community
o appointment of a local fund-raiser will raise the image of the new
palliative care service and hopefully bring in essential income for its
development
" ideally, this should be someone with no clinical
responsibilities
There is no one way to handle all these potential conflicts and problems. They
call for patience, tact, diplomacy and courtesy.
Considerations of Staffing and Recruitment
! palliative care must be multiprofessional or interprofessional
o optimal palliative care requires the co-ordinated input from doctors,
nurses and various allied health professionals
o no one profession can provide palliative care on its own, no matter
how committed they are
o palliative care promoted as nursing care, without any need for
medical involvement, will not be recognized by doctors
! there is often much healthy overlap of roles in an interprofessional
team
o for example nurses can be as effective at counselling as most
doctors, but neither may be as good as a social workers or pastoral
care specialists
o this requires staff to be flexible to avoid conflicts between the
different professions
o there is no place for territorialism in palliative care
o relatives taught to do some nursing care should be seen as
complementing the trained nurses rather than replacing them
! planning the nursing establishment
o depends primarily on the level of dependency of the patients
" patients with different diseases have different nursing needs
" e.g., patients with motor neurone disease (ALS) often need
more nursing care than most cancer patients
o for community-based services, other factors relate to
" the case load
" the distances to be travelled
" whether other community nurses are available
" the availability of doctors with a knowledge of palliative care
" whether the palliative care nurses will do nursing tasks or are
primarily support/resource/advisory nurses
! consider the possibility of sharing staff with other medical services
o sharing social workers, occupational therapists, pastoral care
workers and other allied health personnel, which
" can be an educational experience for each group
" may reduce expenses
o the possibility should always be considered for nurses to rotate
between the hospital and the community palliative care service
once they have been adequately trained
! do not underestimate the need for both pre-service and in-service
training
o many health care professionals (doctors, nurses, and allied health
personnel) think that palliative care is simple
" something that can be done without training, something that
we all do naturally
" others think of it as care of the chronic sick or of the elderly
" some think of it as merely offering psychological support
o the result is that many who apply to work in palliative care services
are totally unsuited for the work
o all personnel working in palliative care for the first time will need
training
! what personal and professional qualities should be looked for when
recruiting staff?
o personality is far more important than anything else
" the undoubted stresses of palliative care are more related to
the personalities of the staff than to the work itself
o they are able to work harmoniously with others
o they are flexible and able to compromise
o previous experience of palliative care, geriatric care and
psychotherapy are not essential
" everyone will need training
" a sense of humour is essential
Educational Responsibilities
! every palliative care service must be prepared to offer an educational
service
o varies from an occasional meeting to a full scale course, according
to local needs and resources
! to share palliative care skills, expertise and enthusiasm with other (nonpalliative
care) health care professionals
o it is to be hoped that they are the ones who will provide most of the
palliative care in the future
Clinical Collaboration
! the ultimate goal in planning a palliative care service is for patients to
receive optimal palliative care wherever they are (in hospital, hospice or
at home), and care which continues in a seamless manner when they
are moved between places of care
! all local health care providers who may be affected by the palliative care
service should be involved in the planning stage, or at least kept well
informed
! details must be discussed from the early planning stages of
o which patients should be referred
o when and how they should be referred
o how the new service will integrate with hospital services
o how the new service will integrate with general practitioners
o availability of diagnostic services