Development and implementation of an inpatient acute palliative care service.

Abstract

Although hospice programs are a well-established feature of the American medical system, inpatient palliative care services are a recent development. Therefore limited data about inpatient palliative care services has been published, and no large series has yet been reported. To describe the development and implementation, as well as the characteristics and effectiveness, of a large inpatient acute palliative care service (APCS). Data on patient demographics, diagnoses, key symptoms, and outcome were collected on each of the 3,712 patients seen from March 1997 to December 2000 by the APCS in a midwestern urban-suburban three-hospital system. Summary statistics were calculated and analyzed. APCS intervention, most common symptoms, and diagnoses, survival, and discharge destination. Of the 3,712 patients seen by the APCS, 56.9% were transferred to the acute palliative care units (APCU) from elsewhere in the hospital, 16.3% were directly admitted to the APCU, and 26.9% were seen in consultation by the APCS without transfer to the APCU. The most common symptoms were dyspnea (53.9%), weakness (42.5%), and pain (40.8%); 88.7% of patients had one to three symptoms. The most frequent diagnoses were cancer (41.3%), cardiac disease (17.4%), pulmonary disease (14.0%), and stroke (9.4%). Of all patients seen by the APCS, 49.5% survived to discharge, although patients whose primary diagnosis was cancer or dementia had significantly higher discharge rates (64.7% and 59.6% respectively, p < 0.001). Of those discharged, 72.0% went home or to an extended care (ECF) with hospice, 13.8% went to an facility ECF without hospice, and 14.2% went home with other home care services. Mount Carmel Health has developed an APCS and APCU integrated into the mainstream of each of its hospitals, providing an opportunity for a more appropriate focus on end-of-life issues for patients with poor prognoses, intense medical needs, and complex family issues.