Authors (including presenting author) :
Wong CK (1), Lai CT (1), Kng PLC (1), Li PY (1), Mak PK (1), Chan YK (1), Law MC (2)
Affiliation :
(1) Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, (2) The Hong Kong Society of Rehabilitation, Jockey Club End-of-life Community Care: ‘Life Rainbow’ End-of-life Care Service
Introduction :
Advance care planning (ACP) is a process of proactive communication to represent patient's wishes and preferences regarding end-of-life (EOL) care. Fragile, vulnerable community-dwelling elders often had repeated hospital admission during their last stage of life, yet most of them lack ACP. Inter-professional collaboration amongst health care providers and social partners have been directly linked to positive outcomes in terms of continuity of care. In view of this, a pilot project was started, to ensure the quality of EOL care service. The Geriatric Team of Ruttonjee & Tang Shiu Kin Hospitals (RTSKH) work partnership with Jockey Club End-of-life Community Care Project (JCECC) to supplement social elements in the medical oriented care planning to make the ACP discussion perfect.
Objectives :
1. Provide seamless coordinated EOL service for home cared elders in end stage of life.
2. Enrich elaboration on the social aspects in ACP to supplement medical dominant care plan making the ACP more comprehensive.
3. Better support the dying persons and their families in community.
4. Improve multi-parties communication in advance care planning process.
Methodology :
Hospital medical team working with non-government organizations (NGO) who provided EOL care for dying people in community setting in order to bridge the gap between hospital-based EOL care and enhancing community support for dying persons. Proactive identification of eligible persons in clinical settings was conducted by geriatricians. During the ACP process, physicians, nurses, community social sectors, patients and family members conjoin with this inter-professional shared decision making process. External social worker could explore personal values and geriatrician explained the treatment options. A mutual understanding on patient’s wish on life-sustaining treatments and preferred care were communicated and documented. To maintain the continuity of care, medical team including geriatricians and nurses work closely with NGOs partners in symptoms management and coordinated hospital admission to designed bed. Home care, transport and psychosocial support at home were provided. Regular follow up, closed-loop communication and interdisciplinary case conference ensure a seamless delivery of EOL care services.
Result & Outcome :
A total of 18 cases were referred to JCECC through geriatricians from RTSKH from July 2019 to December 2019. In which, 94% (n=17) of the referrals accepted the arrangement. Majority 65% (n=11) conjoined with medical doctor in ACP discussion process. Positive feedbacks received from all patients and caregivers. Interdisciplinary collaboration of hospital specialist with community partner to offer team approach without boundary in EOL care was found to be feasible.
