The Going Home Initiative: Getting Critical Care Patients Home With Hospice

Discharging patients home from the intensive care unit: A new trend

Discharging patients directly to home from the intensive care unit (ICU) is becoming a new trend. This review examines the feasibility, benefits, challenges, and considerations of directly discharging ICU patients. By analyzing available evidence and healthcare professionals' experiences, the review explores the potential impacts on patient outcomes and healthcare systems. The practice of direct discharge from the ICU presents both opportunities and complexities. While it can potentially reduce costs, enhance patient comfort, and mitigate complications linked to extended hospitalization, it necessitates meticulous patient selection and robust post-discharge support mechanisms. Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition. Through critical evaluation of existing literature, this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery. The insights provided contribute evidence-based recommendations for refining the direct discharge approach, fostering improved patient outcomes, heightened satisfaction, and streamlined healthcare processes. Ultimately, the review seeks to balance patient-centered care and effective resource utilization within ICU discharge strategies.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review

BACKGROUND

While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied.

AIM

The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings.

DESIGN

We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924).

DATA SOURCES

We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018.

RESULTS

Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization.

CONCLUSION

Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.

Survival and Safety Outcomes of ICU Patients Discharged Directly Home-A Direct From ICU Sent Home Study

OBJECTIVES

Evaluate outcomes (mortality, morbidity, unplanned return visits) of patients who are discharged directly to home from the ICU.

DESIGN

Prospective cohort study.

SETTING

Two tertiary care medical-surgical-trauma ICUs at Canadian hospitals over 1 year (February 2016-2017).

SUBJECTS

All adult patients who were either discharged directly to home (Recruited and Nonrecruited cohorts) from ICU or discharged home within 24 hours after ward transfer (Ward Transfer cohort).

INTERVENTIONS

Direct discharge home from ICU or discharge home within 24 hours of ward transfer from ICU.

MEASUREMENTS AND MAIN RESULTS

One-hundred ninety-eight patients were in the study, 100 patients in the discharged directly to home Recruited arm, 37 patients in the discharged directly to home Nonrecruited arm, and 61 patients in the Ward cohort. All three patient cohorts had 0% mortality at 8 weeks post discharge. The unplanned return visit rate for the Recruited cohort was 24% (emergency department 18%, Ward 4%, ICU 1%), whereas the rate for the Nonrecruited cohort was 52% (emergency department 34%, Ward 14%, ICU 3%) and the Ward Transfer cohort was 46% (emergency department 17%, Ward 26%, ICU 3%) (p = 0.005). No home support was available for 7% of the discharged directly to home Recruited cohort. Twenty-four percent of patients had funded home care nursing, but the majority of patients (81%) relied on help from friends/family.

CONCLUSIONS

Recruited discharged directly to home patients experienced very good 8-week postdischarge outcomes with 0% mortality and a low rate of ICU readmission (1%) or ward readmission (4%), but not an insignificant rate of emergency department visits (18%). Recruited discharged directly to home patients had better outcomes compared with nonrecruited discharged directly to home patients and patients transferred briefly to the ward prior to discharge home. Future work should include derivation of a clinical prediction tool to identify patient characteristics that make discharged directly to home safe and a randomized control trial to compare discharged directly to home with short stay ward transfers.

Going home to die from critical care: A case study

Much of the activity in critical care is complex but repetitive. In order to standardize care and maintain safety, delivery of care is often directed by protocols and care bundles. This case study will reflect on an instance where care transcended the standard protocol-directed path to be more individualized, creative and compassionate. Acts like these can be unique for the practitioners involved and require an element of positive risk taking, which happened here. It will look at the decision-making, planning and risk involved in preparing for a terminally ill patient, who was inotrope and high-flow oxygen dependent, to go home to have treatment withdrawn there instead of in the hospital. This was to fulfil his wish to die at home. In unpicking the circumstances where this positive risk taking led to the desired outcome and the relationship between safety, uncertainty and risk, three themes arose. These were the journey to safe uncertainty; decision-making with uncertain outcomes; and the importance of robust human factors, particularly effective communication and inter-professional teamwork. If positive risk taking can result in enhanced outcomes for the patient, then the question of how this behaviour can be fostered and encouraged must be addressed.

Transferring critically ill babies and children home to die from intensive care

BACKGROUND

A significant proportion of hospital deaths occur in intensive care units (ICU) and often follow a decision to limit or withdraw life-sustaining treatment. Facilitating the preferred choice in place of death for babies/children is increasingly being advocated, although the literature on a home death is often limited to case reports.

AIMS AND OBJECTIVES

To examine (a) health care professionals' (HCPs) views and experience of transferring babies/children home to die from intensive care, (b) patient clinical characteristics that HCPs would consider transferring home and (c) barriers to transferring home.

DESIGN

A cross-sectional descriptive web-based survey.

METHODS

A total of 900 HCPs from paediatric and neonatal ICU across the United Kingdom were invited to participate.

RESULTS

A total of 191 (22%) respondents completed the survey; 135 (70.7%) reported being involved in transferring home to die. However, most (58.4%) had just transferred one or two patients in the last 3 years. Overall, respondents held positive views towards transfer, although there was some evidence of divided opinion. Patients identified as unsuitable for transfer included unstable patients (57.6%) and those in need of cardiovascular support (56%). There was statistically significant difference in views between those with and without experience, in that those with experience had more positive views. The most significant barrier was the lack of access to care in the community.

CONCLUSIONS

HCPs view the concept of transferring critically ill babies/children home to die positively but have infrequent experience. Views held about transfers are influenced by previous experience. The clinical instability of patients and access to community care are central to decision-making.

RELEVANCE TO CLINICAL PRACTICE

A home death for critically ill babies/children is occurring in the United Kingdom but infrequently. Experience of a transfer home positively influences views and increases confidence. Improved multi-organizational collaboration between ICU and community care teams would assist decision-making and facilitation for a transfer home.

Clinical Predictors for Unsafe Direct Discharge Home Patients From Intensive Care Units

PURPOSE

To describe factors (demographics and clinical characteristics) that predict patients who are at an increased risk of adverse events or unplanned return visits to a health-care facility following discharge direct to home (DDH) from intensive care units (ICUs).

METHODS

Prospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between February 2016 and 2017 and were discharged directly home. Patients were followed for 8 weeks postdischarge. Univariable and multivariable logistic regression analyses were performed to identify factors associated with adverse events or unplanned return visits to a health-care facility following DDH from ICU.

RESULTS

A total of 129 DDH patients were enrolled and completed the 8-week follow-up. We identified 39 unplanned return visits (URVs). There was 0% mortality at 8 weeks postdischarge. Eight potential predictors of hospital URVs (P < .2) were identified in the univariable analysis: prior substance abuse (odds ratio [OR] of URV of 2.50 [95% confidence interval: 1.08-5.80], hepatitis (OR: 6.92 [1.68-28.48]), sepsis (OR: 11.03 [1.19-102.29]), admission nine equivalents of nursing manpower score (NEMS) <24 (OR: 2.28 [1.03-5.04], no fixed address (OR: 22.9 [1.2-437.3]), ICU length of stay (LOS) <2 days (OR: 2.95 [1.28-6.78]), home discharge within London, Ontario (OR: 2.44 [1.00-5.92]), and left against medical advice (AMA; OR: 6.06 [2.04-17.98]).

CONCLUSIONS

Our study identified 8 covariates that were potential predictors of URV: prior substance abuse, hepatitis, sepsis, admission NEMS <24, no fixed address, ICU LOS <2 days, home discharge within London, Ontario, and left AMA. The practice of direct discharges home from the ICU would benefit from adequately powered multicenter study in order to construct a clinical prediction model (that would require further testing and validation).

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study

IMPORTANCE

The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.

OBJECTIVE

To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.

EXPOSURES

Patient disposition on discharge from the ICU: directly home vs home via the hospital ward.

MAIN OUTCOMES AND MEASURES

The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year.

RESULTS

Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35).

CONCLUSIONS AND RELEVANCE

The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

Lessons learned and new directions regarding Discharge Direct from Adult Intensive Care Units Sent Home (DISH): A narrative review

Purpose

To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice.

Methods

We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria.

Results

Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH.

Conclusions

This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.

[Palliative care : Challenges in the intensive care unit]

Intensive care unit (ICU) stays often result due to an acute, potentially life-threatening illness or aggravation of a chronic life-threatening illness. In many cases, ICU patients die after life-sustaining treatments are withdrawn or withheld. When patients are asked, they prefer to die at home, although logistic and medical problems often prevent this. Therefore, attention focuses on care at the end of life in the ICU. Despite many efforts to improve the quality of care, evidence suggests that the quality in hospitals varies significantly and that palliative care in the ICU has not significantly improved over time. In this review, aspects of palliative care that are specific to ICU patients are discussed.

Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home Study

Background:

In the new era of decreasing hospital bed availability, there is an increasing rate of direct discharge to home (DDH) from intensive care units (ICUs), despite sparse literature informing this practice.

Objectives:

To evaluate patient, family, and ICU attending physician satisfaction with planning for DDH from the ICU and intensivists’ current DDH practices and perceptions.

Methods:

Prospective cohort study, using convenience sampling, of adult patients undergoing DDH from an ICU between February 2016 and February 2017 using a modified FS-ICU 24 satisfaction survey completed by patients, family members, and attending physicians at the time of patient discharge to home from the ICU.

Results:

Seventy-two percent of patients, 37% of family members, and 100% of ICU physicians recruited completed the survey. A majority of patients (89%) and families (78%) were satisfied or very satisfied with DDH. Only 6% of patients and 8% of families were dissatisfied to very dissatisfied with DDH. Conversely, ICU physician satisfaction varied, with only 5% being very comfortable with DDH and the majority (50%) only somewhat comfortable. Twenty percent of staff consultants were uncomfortable to very uncomfortable with the practice of DDH. Thirty-one percent of staff physician respondents felt that patient and family discomfort would be barriers to DDH. Compared to physicians and other allied health professionals, nurses were identified as the most helpful members of the health-care team in preparation for DDH by 98% of patients and 92% of family members. The DDH rates have increased for the past 12 years in our ICUs but declined during the study period (February 2016 to February 2017).

Conclusions:

Patients and family members are satisfied with the practice of DDH from ICU, although ICU physician satisfaction is more variable. Physician comfort may be improved by data informing which patients may be safely DDH from the ICU.

Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home Study

OBJECTIVES

To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteristics that make them candidates for safe DDH and describe transfer delay impact on length of stay (LOS).

METHODS

Retrospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between April 2003 and March 2015.

RESULTS

Median age was 49 years (interquartile range [IQR]: 33.5-60.4), and the majority of the patients were males (54.8%). Median number of preexisting comorbidities was 5 (IQR: 2-7) diagnoses. Discharge directly to home increased from 28 (3.1% of all survivors) patients in 2003 to 120 (12.5%) patients in 2014. The mean annual rate of DDH was between 11% and 12% over the last 6 years. Approximately 62% (n = 397) of patients waited longer than 4 hours for a ward bed, with a median delay of 2.0 days (IQR: 0.5-4.7) before being DDH. There was an inverse correlation between ICU occupancy and DDH rates ( r_P = -.55, P < .0001, 95% confidence interval [CI] = -0.36 to -0.69, R² = .29). There was no correlation with ward occupancy and DDH rates ( r_s = -.055, P = .64, 95% CI = -0.25 to 0.21).

CONCLUSIONS

The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.

Transferring patients home to die: what is the potential population in UK critical care units?

OBJECTIVES

Most people when asked, express a preference to die at home, but little is known about whether this is an option for critically ill patients. A retrospective cohort study was undertaken to describe the size and characteristics of the critical care population who could potentially be transferred home to die if they expressed such a wish.

METHODS

Medical notes of all patients who died in, or within 5 days of discharge from seven critical care units across two hospital sites over a 12-month period were reviewed. Inclusion/exclusion criteria were developed and applied to identify the number of patients who had potential to be transferred home to die and demographic and clinical data (eg, conscious state, respiratory and cardiac support therapies) collected.

RESULTS

7844 patients were admitted over a 12-month period. 422 (5.4%) patients died. Using the criteria developed 100 (23.7%) patients could have potentially been transferred home to die. Of these 41 (41%) patients were diagnosed with respiratory disease. 53 (53%) patients were conscious, 47 (47%) patients were self-ventilating breathing room air/oxygen via a mask. 20 (20%) patients were ventilated via an endotracheal tube. 76 (76%) patients were not requiring inotropes/vasopressors. Mean time between discussion about treatment withdrawal and time of death was 36.4 h (SD=46.48). No patients in this cohort were transferred home.

CONCLUSIONS

A little over 20% of patients dying in critical care demonstrate potential to be transferred home to die. Staff should actively consider the practice of transferring home as an option for care at end of life for these patients.

'Rapid discharge': issues for hospital-based nurses in discharging cancer patients home to die

AIMS AND OBJECTIVES

To explore issues for hospital-based nurses in arranging rapid home discharge for imminently dying cancer patients in a Singapore acute hospital.

BACKGROUND

Dying at home is an important measure of a 'good death'. For hospitalised terminally ill patients, achieving home death can be of paramount importance to them and their family. Nurses experience many challenges in discharging imminently dying cancer patients home, due to time limitations and complex needs of patients and their families.

DESIGN

Qualitative interpretive description.

METHOD

Using purposive sampling, 14 registered nurses from an oncology ward in a Singapore hospital were recruited to participate in individual, semi-structured interviews.

RESULTS

Nursing issues in facilitating rapid discharge fell into three categories: time, discharge processes and family preparation. Decisions to die at home appeared solely family/patient driven, and were made when death appeared imminent. Discharge then became time-critical, as nurses needed to complete multiple tasks within short timeframes. Stress was further exacerbated by nurses' inexperience and the infrequent occurrence of rapid discharge, as well as absence of standardised discharge framework for guidance. Together, the lack of time and discharge processes to enable smooth hospital-to-home transition potentially affected nurses' capacity to adequately prepare families, and may contribute to caregiver anxiety.

CONCLUSION

Rapid discharge processes are needed as sudden patient/family decisions to die at home will continue. Earlier involvement of palliative care and implementation of a discharge pathway can potentially help nurses address their multiple responsibilities to ensure a successful transition from hospital to home.

RELEVANCE TO CLINICAL PRACTICE

Recognition of nursing issues and challenges during rapid discharge has implications for clinical improvements in supporting nurses during this challenging situation. Results of this study can be used to inform the conceptualisation of clinical interventions to facilitate urgent discharges of imminently dying patients.

A national survey exploring views and experience of health professionals about transferring patients from critical care home to die

BACKGROUND

Transferring critically ill patients home to die is poorly explored in the literature to date. This practice is rare, and there is a need to understand health care professionals' (HCP) experience and views.

OBJECTIVES

To examine (1) HCPs' experience of transferring patients home to die from critical care, (2) HCPs' views about transfer and (3) characteristics of patients, HCPs would hypothetically consider transferring home to die.

DESIGN

A national study developing a web-based survey, which was sent to the lead doctors and nurses in critical care units.

SETTING/PARTICIPANTS

Lead doctors and senior nurses (756 individuals) working in 409 critical care units across the United Kingdom were invited to participate in the survey.

RESULTS

In total, 180 (23.8%) completed surveys were received. A total of 65 (36.1%) respondents had been actively involved in transferring patients home to die and 28 (15.5%) had been involved in discussions that did not lead to transfer. Respondents were supportive of the idea of transfer home to die (88.8%). Patients identified by respondents as unsuitable for transfer included unstable patients (61.8%), intubated and ventilated patients (68.5%) and patients receiving inotropes (65.7%). There were statistically significant differences in views between those with and without experience and between doctors and nurses. Nurses and those with experience tended to have more positive views.

CONCLUSION

While transferring patients home to die is supported in critical care, its frequency in practice remains low. Patient stability and level of intervention are important factors in decision-making in this area. Views held about this practice are influenced by previous experience and the professional role held.

Doctors' and nurses' views and experience of transferring patients from critical care home to die: a qualitative exploratory study

BACKGROUND

Dying patients would prefer to die at home, and therefore a goal of end-of-life care is to offer choice regarding where patients die. However, whether it is feasible to offer this option to patients within critical care units and whether teams are willing to consider this option has gained limited exploration internationally.

AIM

To examine current experiences of, practices in and views towards transferring patients in critical care settings home to die.

DESIGN

Exploratory two-stage qualitative study

SETTING/PARTICIPANTS

Six focus groups were held with doctors and nurses from four intensive care units across two large hospital sites in England, general practitioners and community nurses from one community service in the south of England and members of a Patient and Public Forum. A further 15 nurses and 6 consultants from critical care units across the United Kingdom participated in follow-on telephone interviews.

FINDINGS

The practice of transferring critically ill patients home to die is a rare event in the United Kingdom, despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death and the view that transfer to community services is a complex, highly time-dependent undertaking.

CONCLUSION

There are evidenced individual and policy drivers promoting high-quality care for all adults approaching the end of life encompassing preferred place of death. While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting.

Coming and going: predicting the discharge of cancer patients admitted to a palliative care unit: easier than thought?

PURPOSE

Discharging a patient admitted to an inpatient palliative care unit (PCU) is a major challenge. A predictor of the feasibility of home discharge at the time of admission would be very useful. We tried to identify such predictors in a prospective observational study.

METHODS

Sixty patients with advanced cancer admitted to a PCU were enrolled. Sociodemographic data were recorded and a panel of laboratory tests performed. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were determined. A palliative care physician and nurse independently predicted whether the patient would die at the ward. The association of these variables with home discharge or death at the PCU was determined.

RESULTS

Sixty patients (26 men and 34 women) with advanced cancer were included in the study. Discharge was achieved in 45 % of patients, while 55 % of patients died at the PCU. The median stay of discharged patients was 15.2 days, and the median stay of deceased patients 13.6 days. Median KPS and PPS on admission was 56.2 % for the entire group and significantly higher for discharged patients (60.7 %) compared to deceased patients (52.4 %). Median BMI on admission was 22.8 in the entire group and was similar in discharged and deceased patients. No correlation was found between a panel of sociodemographic variables and laboratory tests with regard to discharge or death. In a binary logistic regression model, the probability of discharge as estimated by the nurse/physician and the KPS and PPS were highly significant (p = 0.008).

CONCLUSION

Estimation by a nurse and a physician were highly significant predictors of the likelihood of discharge and remained significant in a multivariate logistic regression model including KPS and PPS. Other variables, such as a panel of laboratory tests or sociodemographic variables, were not associated with discharge or death.

Can the Communion of Saints Help the Search for Justice in Dying well (Enough), "In Abraham's Arms, Where Lazarus is Poor no Longer"?

How can we practice dying in community? What communal practices nourish positive acts that make dying well (enough)-more than prudent caution in avoiding causing death (killing)? What part of our common ecclesial life as Catholics enables us to accompany dying persons as a gracious return to God? We are twice haunted: most first world deaths result from foreseen end-stage illnesses; mortality is less feared than burdensomeness for caregivers from vulnerable dependence. Of those who die in the hospital, many deaths result from decisions to withhold and withdraw treatments. From ten kinds of desolation about dying, ten parallel consolations are discerned in hopes and outcomes-based best practices.