Dear Editor,
discussions about the optimal model for qualifying patients for palliative and hospice care continue [1]. The present legal system in Poland only defines the general organisational framework for this process. They are limited only by a list of diagnoses with no hope of a cure or, as per the Ministry of Health’s definition of palliative and hospice care, not amenable to causal treatment [2].
There is a two-stage eligibility process for care. The first one involves the analysis of a medical referral and accompanying medical records by a palliative and hospice care facility. This draws on the information provided in the referral and the patient’s available medical records. The referring physician is obliged to include the information necessary for initiating treatment and care [3], but the legislator does not specify which medical indications (apart from the disease diagnosis) are relevant for making appropriate eligibility or disqualification decisions. Meanwhile, based on this information at the time of registration, the palliative and hospice care facility should classify the patient as an urgent or stable case. Consequently, the former should be offered to start care earlier (setting a date for consultation in the patient’s home or admission to inpatient care). In the second eligibility stage, during the first consultation, the palliative and hospice care physician decides to admit or refuse admission based on the clinical examination.
Currently, palliative and hospice care facilities are guided by medical indications for care (including the initiation of urgent or stable care) selected ad hoc. This is due to the lack of uniform recommendations and different environmental conditions (e.g. large city vs. rural area). In a recent literature review, medical indications for adult patients were presented, divided into those dependent on the severity of the condition and those related to the patient’s needs [4]. While defining the severity of a life-threatening condition is not very difficult in practice, trying to determine the needs of patients that go beyond the elements of palliative care (provided by other medical specialities) is still a considerable challenge. The most common examples are the significant severity, complexity or persistence of problems and the difficulty in defining consistent goals of care, especially at the end of life, which requires the dynamic and comprehensive support of a multidisciplinary team.
The literature provides different methods to determine both the palliative and hospice care needs of patients and the burden of symptoms or problems on the patient. Screening methods should include the patient’s physical, emotional and social spheres and the needs of the carers while being simple and acceptable to use. In my opinion, the assessment should not set a rigid threshold determining admission but should leave sufficient flexibility for the doctor to make an appropriate decision, depending on the individual environmental conditions in which the palliative and hospice care facility operates. In addition, the tool used to assess the patient during admission should make it easy to document the reasons behind a decision to admit or refuse admission. In the future, it could be used, for example, to monitor the profile of patients admitted and discharged and compare the quality of care or the funding of services.
The Hospice and Palliative Care Evaluation Symptoms and Problems Checklist (HOPE-SP-CL), which has been used in Germany for several decades, appears to be a valuable screening tool for assessing patients’ palliative and hospice care needs [5, 6]. It involves assessing seventeen problems by a palliative and hospice care team member on a four-point verbal scale (none, mild, moderate, severe) using a score from 0 to 3. The total score illustrates the severity of the problem burden from 0 (lowest) to 51 (highest). It includes physical, nursing, psychological and social categories, with an optional additional problem (Table 1). The HOPE-SP-CL is derived from the Edmonton Symptom Assessment System (ESAS) [7], recommended as a screening tool in national consultant standards [8], and is also consistent with the Summary of Work of the Palliative and Hospice Care Team [9]. In an era of increasing awareness of the professional competencies of palliative care nurses, this tool could be successfully used in the eligibility process of patients for care by this professional group as well [10]. Therefore, it is worth considering the introduction of this tool to national settings.
|
Problem |
Severity |
|||
|
None |
Mild |
Moderate |
Severe |
|
|
Pain |
0 |
1 |
2 |
3 |
|
Nausea |
0 |
1 |
2 |
3 |
|
Vomiting |
0 |
1 |
2 |
3 |
|
Dyspnoea |
0 |
1 |
2 |
3 |
|
Constipation |
0 |
1 |
2 |
3 |
|
Weakness |
0 |
1 |
2 |
3 |
|
Loss of appetite |
0 |
1 |
2 |
3 |
|
Tiredness |
0 |
1 |
2 |
3 |
|
Wound care |
0 |
1 |
2 |
3 |
|
Assistance with activities of daily living |
0 |
1 |
2 |
3 |
|
Depression |
0 |
1 |
2 |
3 |
|
Anxiety |
0 |
1 |
2 |
3 |
|
Tension |
0 |
1 |
2 |
3 |
|
Disorientation/confusion |
0 |
1 |
2 |
3 |
|
Organization of care |
0 |
1 |
2 |
3 |
|
Overburdening of family |
0 |
1 |
2 |
3 |
|
Additional |
0 |
1 |
2 |
3 |
Declaration of conflict of interest
The author declares that there is no conflict of interest.
Funding
None declared.
