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Establishing a Palliative Care Unit: The UCSF Comfort Care Suites Example

Establishing a Palliative Care Unit: The UCSF Comfort Care Suites Example. Stephen J. McPhee, M.D. Julie Koppel, R.N. University of California, San Francisco. Naming the Unit: Comfort Care Suites (CCS). Name emphasizes primary goals: Ensuring patient comfort Attending to family needs

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Establishing a Palliative Care Unit: The UCSF Comfort Care Suites Example

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  1. Establishing a Palliative Care Unit: The UCSF Comfort Care Suites Example Stephen J. McPhee, M.D. Julie Koppel, R.N. University of California, San Francisco

  2. Naming the Unit: Comfort Care Suites (CCS) • Name emphasizes primary goals: Ensuring patient comfort Attending to family needs • Avoids negative connotations for patient/family of “palliative care” • Avoids confusion with “CCU”

  3. Description • 2 rooms adjacent to one another and a solarium on 14-Long medicine-oncology ward (“swing beds”) • More home-like decor, with living room • Pull-out couches allow families to stay overnight, keep vigil

  4. Physical Environment • Sound-proof (intercom removed) • Commanding views of San Francisco Bay, Mount Sutro eucalyptus forest • Medical equipment available, masked by cabinetry

  5. Physical Environment (cont’d) • Parquet flooring (vinyl) • Nature motif (to bring outdoors in): Décor, art, fountain • Stereo, CD player, TV, VCR • Books, magazines, subscriptions • Display cabinet of spiritual icons

  6. Planning Process • Outgrowth of “jury-rigged” suites • Committee convened 1998, met every two weeks • Site visits to three Bay Area inpatient hospices • In-service training of 14-L nurses by home hospice agency • Rooms allocated, renovated • Opening reception in March, 1999

  7. Fund Raising • Hospital administration (Director of Nursing, CEO) • Hospitals Auxiliary • Donations Staff Patients, families

  8. Palliative Care Consultation Service • Team: 14-L nurses Attendings (2--6): General medicine, hospitalists, geriatrics Pharmacist Chaplain, CPE interns Social workers Ethicist

  9. Palliative Care Consultation Service: (“Recommendation Only” Model) • Patient: Continues on service of referring attending, housestaff • CCS attendings: Operate as consultants • Orders: Written by referring housestaff according to CCS protocol

  10. Admission Criteria Patient is terminally ill, no longer pursuing curative treatment, and: • Death imminent (days to a week) • Needs palliative symptom management • Patient, family and/or team needs assistance with or plans to focus on: Communication issues around death and dying Advance directive issues Providing comfort and support to the patient and family

  11. CCS Patients • Patients who the primary service believes are appropriate for the Comfort Care Suites • Patients may be admitted from 14 Long or another unit, any intensive care unit, the emergency department, or directly from home or an outside institution • Family conference or discussion must occur • “D” word (“death” or “dying” ) used • “This is broken, and we cannot fix it.”

  12. Protocol Orders 1. Admit to room 2. Contact CCS consultation team 3. Contact chaplain 4. CCS diagnosis/reason for transfer 5. Other medical diagnoses 6. Code status 7. Care plan

  13. Protocol Orders 8. Vital signs (optional) 9. Call house officer (optional) 10. Diet (as tolerated) 11. Oral care (as per RN) 12. Pain control 13. Dyspnea 14. Anxiety

  14. Protocol Orders 15. Secretions (e.g., atropine ophthalmic) 16. Constipation 17. Diarrhea 18. Nausea and Vomiting 19. Insomnia

  15. Billing for Services • Billing diagnosis must differ from underlying medical diagnosis (e.g., “intractable dyspnea” instead of “cystic fibrosis”) • V66.7 code - palliative care code

  16. Billing for Services • Time codes - document time spent with patient, family, floor/unit time • “Asked to see patient at request of Dr. (Attending)” • “Review of symptoms cannot be obtained because…” • “Patient seen, examined, and discussed with Dr. (Resident/Attending)”

  17. Questions? • Resources: • Protocol orders • von Gunten CF. "Perspectives on Care at the Close of Life. Secondary and Tertiary Palliative Care in US Hospitals." Journal of the American Medical Association, 2002;287(7): 875-81.

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