INTRODUCTION

‘Out-of-hours’ is defined as time outside the working hours of “PALCARE” that is evenings (from 05:30 pm – 09:30 am), weekends from Friday evening to Monday morning, and public holidays. Most of the cancer patients spend their last days of their life at home and at least two-thirds of this is ‘out of hours’. Despite careful planning, unexpected deterioration may occur.

If such sudden or unexpected deterioration or uncontrolled/worsening symptoms occurs during out of hours, it may lead to any of the following scenarios:

• Requesting a general practitioner (GP) / family physician (FP) to visit
• Transfer of patient from home to hospice
• Transfer of patient from home to hospital

MANAGEMENT

• Inform patients and carers about sources of help out-of-hours and what services to expect
• Provide 24-hour telephonic service from a single point of access to all out-of-hours services to benefit patients and carers. This can offer simple and convenient access, so that appropriate care can be delivered quickly, effectively and efficiently
• Accessibility of GP/FP and nursing support during out-of-hours care should be identified and provided whenever possible
• Access to specialist palliative care advice on symptom management, palliative care medications and their administration should be provided
• Anticipatory planning should be done to ‘ensure that there is availability of medications in the patient’s home, combined with technical support necessary to administer them for use after an appropriate clinical assessment by a doctor’ (refer to the Guideline – Anticipatory Prescribing)
• An ‘end-of-life’ medication box, containing appropriate medications and information charts, duly signed by the doctor in charge, should be left with the carer, and should contain sufficient stock to last 48-72 hours. This will help in avoiding unnecessary hospital admissions and will help provide patients a choice for preferred place of care (refer to the Guideline – Anticipatory Prescribing)
• PALCARE doctors should anticipate difficult symptom control/rapid deterioration in their patients cared for at home and recognise the necessity of information handover to the GP/FP and those involved with care of the patient
• The information should include:
• Patient and caregiver details
• Details of diagnosis
• Co-morbidities
• Allergies, drug reactions
• Curative treatments undertaken
• Patient’s understanding of diagnosis and prognosis
• Family’s understanding of diagnosis and prognosis
• Wishes of patient and family including preferred place of care
• Present medications including dose and route of administration
• Any care considerations such as catheter care, naso-gastric tube care, PEG care etc.
• Any equipment such as syringe pump, wheel chair, nebuliser etc.
• Anticipatory medications provided and details of the same
• Availability of advance care plan including discussions on active life sustaining interventions such as CPR and artificial ventilation
• Has it been discussed?
• If yes, what is the present status?
• An information handover form containing up-to-date information summary should be left at home of the patient with the patient file kept at home
• Transport issues should be addressed, and contact details of ambulance services should be provided for speedy resolution of the request for ambulance services
• Family/carers should be communicated the risk of death during transfer
• When a patient is transferred to hospice/hospital every effort should be made to establish communication with the treating health care professional at the hospice/hospital at the earliest
• Assess for any lacunae in information provided to the healthcare professional at hospice/hospital and provide the necessary information
• Coordinate with the hospital/ hospice team to ensure continuity of care in the event of patient being discharged home from hospice/hospital

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REFERENCES

• Adam, J. (2006). Community Palliative Care. ABC of Palliative Care (pp. 68-73)
• Healthcare Improvement Scotland. Scottish Palliative Care Guidelines – Out of Hours Handover. Retrieved online from https://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/out-of-hours-handover.aspx on 9 January 2019
• Healthcare Improvement Scotland. Scottish Palliative Care Guidelines – Rapid Transfer Home in the Last Days of Live. Retrieved online from https://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/rapid-transfer-home-in-the-last-days-of-life.aspx on 9 January 2019
• Macmillan cancer relief. Continuing care for the dying at home: Out-of-hours palliative care in the community – March 2001. Retrieved online from https://www.palliativedrugs.com/download/OOHReport.pdf on 9 January 2019
• Schweitzer, B., Blankenstein, N., Slort, W., Knol, D.L., Deliens, L., Van der Horst, H. Writing information transfers for out-of-hours palliative care: a controlled trial among GPs. Scandinavian Journal of Primary Health Care. (2016); 34(2): 186-195
• Worth, A., Boyd, K., Kendall, M., Heaney, D., Macleod, U, Cormie, P., Hockley, J., Murray, S. Out-of-hours palliative care: a qualitative study of cancer patients, carers and professionals. British Journal of General Practice. (2006); 56(522): 6-13