Transfers and staff changes create very real problems for patients and providers. The average hospital patient may see as many as a dozen different physicians and a dozen different nursing personnel in one day! Home care patients, too, may see a number of different health care providers - nurses, health aides, physical therapists, counselors, and volunteers. The personnel parade can take an emotional toll on patients and their caregivers. Repeated transfers or changes among health care providers contributes to a loss of empathy, intimacy, trust, and promise keeping - the very factors so critical to good care at the end of life.
Being transferred from one unit to another - from the ICU, for instance, to a general medical ward, when the patient has only 48 hours to live - can be very disruptive to patients and families.
Transfers create the following kinds of problems for patients, families, and health care providers:
For systems, transferring patients from one setting to another - from the nursing home, for instance, to the emergency room - permits a critical lack of accountability. Everyone involved with the patient's care can fall back on not knowing enough about the patient, his or her preferences, or his or her treatment plan. It is easy to claim that something is not one's problem, duty, or responsibility.
In many systems, various units do not even view themselves as being integrated or interdependent. The emergency medical system may not view itself as having some accountability to the intensive care system, which in turn does not see itself as part of the medical/surgical system. Each operating unit views itself in isolation from the others; it is as if a quarterback just decided to pass without even looking for a receiver.
What can organizations do to prevent unnecessary transfers? They can develop the capacity to meet patient needs, regardless of which unit they are in, along with policies of "compassionate nondischarge." These policies, which are already in place at several Catholic hospitals, require that hospitals keep patients, rather than discharge them, when death is likely to occur within 48 hours, even if a hospital level of care is unnecessary. This would mean not discharging those who are very near death from the ICU to a medical floor, or not discharging to homes those who would do better to remain in hospitals.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].