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Acta Academiae Medicinae Sinicae

Abbreviation (ISO4): Acta Academiae Medicinae Sinicae      Editor in chief: Xuetao CAO

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Acta Academiae Medicinae Sinicae >

2024 , Vol. 46 >Issue 5: 706 - 710

DOI: https://doi.org/10.3881/j.issn.1000-503X.16062

Hospice and Palliative Care Column

Experience of Integrative Palliative Care at Peking Union Medical College Hospital

  • Ruixuan GENG 1 ,
  • Ying ZHENG 2 ,
  • Chenchen SUN 2 ,
  • Xi ZENG 3 ,
  • Hongyan FANG 3 ,
  • Wenqian ZHAN 3 ,
  • Yuanfeng YU 4 ,
  • Qin YANG 4 ,
  • Xiaoyan DAI 1 ,
  • Xiaohong NING , 2
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  • 1Department of International Medical Services,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
  • 2Palliative Medicine Center,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
  • 3Palliative Medicine Center,The People’s Hospital of Guangxi Zhuang Autonomous Region,Nanning 530021,China
  • 4Department of Palliative Care,Deyang Hospital,Affiliated Hospital of Chengdu University of Traditional Chinese Medicine,Deyang,Sichuan 618000,China
NING Xiaohong Tel:010-69154065,E-mail:

Received date: 2024-03-04

  Online published: 2024-12-03

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Abstract

Objective to summarize the experience of integrative palliative care at Peking Union medical College Hospital and provide a reference for promoting the integrative palliative care model.Methods Twenty cases receiving integrative palliative care at Peking Union medical College Hospital were collected.the clinical characteristics,reasons for initiating integrative palliative care,the process of integrative palliative care,and feedback from these cases were summarized.Results Insomnia(11 cases,55%)and pain(9 cases,45%)were the most common symptoms requiring control in the 20 cases.the integrative palliative care team assisted in Medical decision-making for 17 cases(85%),prepared end-of-life for 9 cases(45%),assisted in the transfer for 3 cases(15%),and provided comfort care for all the 20 cases(100%).Conclusions the integrative palliative care model can help alleviate suffering in end-of-life patients and provide support To patients’families and the original Medical teams.This model is worth further promotion within class A tertiary hospitals。

Key words： integrative palliative care; symptom control; shared decision-making

Cite this article

Ruixuan GENG , Ying ZHENG , Chenchen SUN , Xi ZENG , Hongyan FANG , Wenqian ZHAN , Yuanfeng YU , Qin YANG , Xiaoyan DAI , Xiaohong NING . Experience of Integrative Palliative Care at Peking Union Medical College Hospital[J]. Acta Academiae Medicinae Sinicae, 2024 , 46(5) : 706 -710 . DOI: 10.3881/j.issn.1000-503X.16062

Palliative care can provide holistic care for patients and families with life-threatening diseases, improve the quality of life of patients, and support families[1]. In-hospital palliative care services in large 3A hospitals in China have not yet been widely carried out, and in a few hospitals with palliative care practice, the attending department usually invites the palliative care team to consult to meet the needs of multiple departments in the hospital. The survey of medical staff shows that palliative medical consultation can build a bridge between doctors and patients, give psychological and technical support to medical staff, help to understand multidisciplinary team consultation, and make up for the lack of humanistic care in the medical process[2]. However, in palliative care consultation, the original medical team often has problems such as lack of experience in facing death, job burnout, and tense doctor-patient relationship, and the consultation itself also has limitations such as discontinuous service, inability to continuously follow up symptom control and communication effect. Drawing on the practical experience of Singapore and other countries, and with the approval of the Medical Department of Peking Union Medical College Hospital, the Palliative Care Center has launched a service model jointly managed by the original medical team and the palliative care team since April 2023, aiming at providing timely and effective palliative care for patients and their families through multidisciplinary and multi-center teamwork[3-4]. This study summarized the cases of palliative care co-management in Peking Union Medical College Hospital, and provided a reference for further promotion of palliative care co-management model.

1 Data and Methods

1.1 Data sources

the clinical data of 20 patients who received palliative care in Peking Union Medical College Hospital from April to October 2023 were retrospectively analyzed.the inclusion criteria were as follows:(1)difficult to control symptoms,or communication difficulties and other problems related to palliative care;(2)the original medical team needs The help of The palliative medical team and applies for joint management;(3)The palliative medicine center assessed at The first consultation that it was capable of providing assistance and agreed to co-management.This study was approved by the ethics Committee of Peking Union Medical College Hospital(Ethics review number:I-23PJ2224)。

1.2 Data collection

the basic information of patients(age,gender,inpatient department,main diagnosis),the reasons for starting co-management(symptoms,disease cognition,treatment expectation,invasive rescue intention,care and death place,afterlife,grief assessment,comfort care),and the process of co-management(duration,rounds,reasons for closing the case)were extracted from the inpatient electronic medical record system。

1.3 Common Management Model

1.3.1 Commencement of Co-management

If the patient needs the help of the palliative medical team,the original medical team will make a request for consultation according to the patient's needs,and the palliative medical center will evaluate and communicate with the patient.If they think they have the ability to provide help,the original medical team shall submit an application for joint management.After the application is filed by the medical department,the doctors of the palliative medical center shall be included in the list of doctors of the original medical team,and the joint management procedure shall be formally initiated。

1.3.2 Participants

the attending physician of the original medical team and the physician of the palliative care center are the co-responsible physicians of the patient.the nurse in charge of the former medical team and the nurse in charge of the palliative care center are the co-nurses of the patients.the original medical team and the doctors,nurses and social workers of the palliative care center form a joint management team。

1.3.3 Cooperation model

Patients also receive treatment and care from the palliative care team while receiving the primary disease diagnosis and treatment from the original medical team.the intervention of the palliative care team did not affect the treatment dominance of the original medical team.palliative care physicians also have the right to co-manage the patient's prescription and complete the work of issuing medical orders.the palliative care center made ward rounds 3 to 5 times a week as needed,and the course of the disease was recorded.the joint management team establishes an exclusive working group for each patient,and shares information within the group to ensure timely and effective communication within the team。

1.3.4 End of joint management

When the patient dies or is discharged from the hospital,or after the evaluation and communication of the palliative medicine center,it is judged that the joint management task has been completed,and it is considered that the relevant joint management work can be ended。

2 Results

2.1 General

of The 20 patients who received co-management,10 were male and 10 were female,with a median age of 65.5 years(range,19.0 to 98.0 years).Among them,there were 7 cases of respiratory medicine(35%),3 cases of emergency department(15%),3 cases of international medical department(15%),1 case of traditional Chinese medicine(5%)and 1 case of infectious medicine(5%).the main diagnosis was malignancy in 16 patients(80%),shock in 2 patients(10%),end-stage renal disease in 1 patient(5%)and disturbance of consciousness in 1 patient(5%)(Table 1)。
表1 Basic information of 20 patients receiving palliative care co-management
序号 年龄
(岁)		 性别 科室 主要诊断 启动共同管理的原因 结案原因
症状控制 医疗决策与离世准备 舒适护理
1 42 女 中医科 宫颈癌 呼吸困难 协助转诊 口干护理、舒适体位、皮肤护理、药物指导 出院
2 79 男 感染内科 感染性休克 共同决策 口干护理、舒适体位、皮肤护理、疼痛宣教 离世
3 37 女 产科 肝癌 疼痛、腹胀、浮肿、便秘、失眠 共同决策 口干护理、憋气护理、舒适体位、营养指导、情绪支持 出院
4 61 女 呼吸内科 肺癌 疼痛、失眠、口干、乏力 共同决策、离世准备、协助转诊 舒适体位、药物指导 出院
5 77 男 普通内科 心源性休克 失眠、躁动 共同决策、离世准备 口干护理、舒适体位 出院
6 64 男 呼吸内科 肺癌 疼痛、失眠、躁动 共同决策、离世准备 舒适体位、疼痛宣教、药物指导 离世
7 70 男 呼吸内科 肺癌 呼吸困难、失眠 共同决策、离世准备 舒适体位、疼痛宣教、药物指导、营养指导 离世
8 65 女 呼吸内科 肺癌 疼痛、呼吸困难、浮肿、失眠、口干 共同决策、离世准备 舒适体位、疼痛宣教、药物指导、便秘宣教 离世
9 88 女 肾内科 终末期肾病 谵妄、躁动 共同决策 舒适体位、疼痛宣教 病情平稳
10 19 女 急诊科 意识障碍 共同决策 口干护理、皮肤护理、舒适体位 出院
11 53 男 急诊科 胆管细胞癌 共同决策、离世准备 口干护理、舒适体位、疼痛宣教 离世
12 89 女 国际医疗部 肝癌 呼吸困难、腹胀、便秘、失眠 共同决策、离世准备 口干护理、皮肤护理、舒适体位、疼痛宣教、便秘宣教、情绪支持、芳香治疗 离世
13 90 男 国际医疗部 淋巴瘤 疼痛、口干、纳差、谵妄 共同决策 口干护理、舒适体位、营养指导 病情平稳
14 71 男 呼吸内科 肺癌 共同决策 舒适体位 出院
15 64 女 呼吸内科 肺癌 疼痛、失眠、纳差 共同决策 口干护理、舒适体位、疼痛宣教 出院
16 64 男 国际医疗部 胃癌 疼痛、腹胀、便秘、恶心、失眠、口干 共同决策、离世准备 口干护理、舒适体位、哀伤辅导、情绪支持 出院
17 98 男 急诊科 肝癌 便秘、乏力 共同决策、协助转诊 口干护理、舒适体位、情绪支持 病情平稳
18 68 男 基本外科 胃癌 疼痛、失眠 口干护理、舒适体位、营养指导、哀伤辅导 出院
19 66 女 呼吸内科 肺癌 疼痛 舒适体位、营养指导、疼痛宣教 病情平稳
20 37 女 神经内科 黑色素瘤 失眠 共同决策、离世准备 口干护理、舒适体位、营养指导、哀伤辅导、情绪支持 出院

2.2 Reasons for starting joint management

2.2.1 Symptom control

of the 20 patients,insomnia(11 cases,55%)and pain(9 cases,45%)were the most common symptoms to be controlled,and other symptoms included dyspnea(4 cases,20%),constipation(4 cases,20%),abdominal distension(3 cases,15%),dry mouth(4 patients,20 percent),restlessness(3 cases,15 percent),anorexia(2 cases,10 percent.For insomnia,7 cases were improved by adding lorazepam,2 cases by adding olanzapine,and 2 cases by improving pain without adding drugs.For patients with cancer pain,the pain was effectively controlled by comprehensive means such as pain cause assessment,medication adjustment and therapeutic communication.For dyspnea,the symptoms of 4 patients were significantly relieved after standard use of morphine。

2.2.2 Medical decision-making and death preparation

Family meetings were held in 8(40%)of the 20 patients.the contents of communication mainly included understanding the disease cognition of patients and their families(12 cases,60%),treatment goals(14 cases,70%),and making medical decisions together(17 cases,85%).Eleven of the 13(65%)patients who talked about invasive rescue intention refused CPR。
the co-management team discussed the place of death with 10 patients(50%),assisted 9 patients(45%)In preparation for death,and assisted 3 patients(15%)in referral to the hospice unit.in addition,the team provided emotional support and grief counseling to 13(65%)family members。

2.2.3 Comfort Care

All the 20 patients were visited,evaluated,instructed by nurses from the Palliative Medicine Center on the care of common end-stage symptoms(dry mouth care in 13 cases,skin care in 4 cases),and assisted in finding comfortable body positions(20 cases,100%).Pain education(9 cases,45%),medication guidance(5 cases,25%)and nutrition guidance(6 cases,30%)carried out by nurses effectively helped patients and their families to implement the doctor's advice and avoid common problems such as insufficient or excessive medication and cough.Aromatherapists at the Palliative Medicine Center also provide aromatherapy services to some patients who need it。

2.3 Co-management process and feedback

Among the 20 patients,the average duration of co-management was 8.6 days(2.0-31.0 days),and the average number of ward rounds was 3.4 times per week.6 cases(30%)were closed due to death,10 cases(50%)were closed due to discharge,and 4 cases(20%)were opened due to stable condition assessed by the palliative Medicine Center.All the family members of the patients who have been jointly managed and the original medical team have highly recognized the joint management model of the palliative care team.feedback from the patient's family members that the palliative care team is very helpful in controlling symptoms and promoting communication within family members;the Feedback from the original medical team was supported by the palliative care team in controlling symptoms and making medical decisions together。

3 Discussion

How to effectively manage end-stage patients is a thorny problem often encountered in clinical practice in various departments of large first-class hospitals.Palliative care provides patient-centered holistic care for end-stage patients and their families by comprehensively assessing the physical,psychological,social and spiritual needs of end-stage patients,alleviating the suffering of patients and their families,and improving the quality of life of patients[1]。 patients in need of palliative care are mostly distributed In different clinical departments in large tertiary hospitals,and the original medical team has different experience in the management of end-stage patients and different understanding of palliative care.in the past,palliative care initiation and follow-up care relied on the original medical team to initiate the consultation.However,this model has limitations.First of all,palliative care has a certain continuity,and a single palliative consultation can only solve part of the problem.If the original medical team no longer initiates the consultation,the patient will face the interruption of palliative care.Secondly,the consultation opinions of the palliative medical team need to be implemented by the doctors of the original medical team,and the original medical team may be unable to implement the consultation orders for fear of adverse drug reactions,thus affecting the treatment effect of patients.in addition,because the palliative care model is different from the traditional medical model,social workers and volunteers often participate in the care of patients,and medical and nursing consultations can not fully reflect the work of the palliative care team.Therefore,it is particularly important to explore a new type of palliative care intervention model and integrate palliative care closely into the patient's diagnosis and treatment process。
Palliative care services based on multidisciplinary teams can comprehensively focus on the multi-dimensional needs of patients and their families and provide them with the services they need[5]。 Thanks to the policy support of Peking Union medical College hospital,our Hospital officially started the attempt of joint management of palliative care in April 2023.Co-management refers to the provision of Medical services and management for patients with long-term and continuous treatment and care needs[6]。 palliative care co-management means that the palliative care team is introduced into the diagnosis and treatment of end-stage patients In various specialties,and the palliative care doctor and the doctor of the original medical team jointly become the doctor in charge of the patient and participate in the treatment and care of the patient.Once co-management is initiated,the palliative care team actively participates in the patient's daily diagnosis and treatment,including communicating with the patient and his family,prescribing medication or treatment for the patient,and making important medical decisions with the original medical team and the patient.Compared with the traditional consultation mode,the co-management mode can find the palliative care needs of patients more timely and intervene timely and adequately,which increases the initiative,timeliness and effectiveness of the implementation of palliative care.in addition,the experience from Singapore shows that the co-management model can reduce the length of hospitalization of patients because it can deal with the core problems faced by end-stage patients more efficiently[3]。
End-stage patients and their families face the upcoming adverse outcome,with increased stress levels and anxiety,depression and other emotions[7]。 These pressures and emotions will lead to patients and their families unable to make rational decisions,or impulsive behavior,which will lead to doctor-patient conflicts,or even doctor-patient conflicts.palliative care co-management fully communicates with patients and their families in the early stage,gives patients and their families sufficient time to accept adverse outcomes,release emotions,and reduces potential doctor-patient conflicts by giving emotional support to their families.On the other hand,under the influence of traditional concepts,the patient's family members may conceal the patient's condition from the patient himself,which leads to the patient himself being unable to express his true intention of treatment due to the limitation of disease cognition.the Palliative care team can assist the original medical team to inform the patient of the condition,and encourage the patient and family members to express their ideas through family meetings,so as to reduce the regret of failing to respect the patient's wishes and achieve the patient's wishes because the family members dare not discuss the condition with the patient。
Medical staff are also under great pressure when facing end-stage patients.the pressure of responsibility in making difficult decisions,the pressure of communication with patients and their families,and the moral pressure of resource allocation are common among doctors.Nurses,on the other hand,need to bear heavy nursing pressure and feel powerless to participate in treatment decision-making[8]。 Palliative Care team can help the original Medical team to communicate,promote the agreement of treatment goals between doctors and patients,avoid unnecessary trauma and pain of patients,and help to alleviate the psychological pressure of the original medical team members.At the same time,in the face of terminal symptoms that are difficult to control,the palliative care team can apply its rich experience to the control of dyspnea,abdominal distension,pain and other symptoms to help the original medical team better manage patients,so as to achieve the effect of patient comfort,family satisfaction and pressure reduction of the original medical team.in addition,the palliative care team can also assist the original medical team to refer patients in need to the Tranquil Palliative care medical Association,accelerate the turnover of beds,help alleviate the pressure on beds in third-class hospitals,and improve hospital efficiency。
the palliative care co-management model achieves a win-win effect through the cooperation between the palliative care team and the original medical team.However,there are still some problems in this model:(1)Due to personnel constraints,the palliative care team does not have emergency or on-duty doctors,such as patients who need emergency treatment at night or on holidays.the physician of the palliative care team can only guide the doctor on duty by telephone,and the doctor on duty may refuse to implement the doctor's advice because he is not familiar with the medicine.(2)When the patient's primary disease has lost the chance of treatment,the original medical team tends to take over the care of the patient by the palliative care team,but because most of the third-level first-class hospitals do not have hospice care or palliative care wards at present,such needs are difficult to meet directly,and the patient can only be referred to the medical ward.in the future,if the scale and personnel of the palliative medicine center can be fully expanded,combined with the publicity for clinical departments and the training of primary palliative concepts and skills for medical staff in the hospital,the palliative care team and clinical departments will achieve closer and smoother cooperation,and more patients with serious illness and pain will receive full care with temperature and quality,so as to truly achieve the goal of improving medical quality,improving medical experience and enhancing patient experience advocated by the state。
this study is the First time to put forward the model of palliative care co-management in China.Through the introduction of the co-management model and the retrospective descriptive analysis of the patients receiving co-management,the application value of the co-management model of palliative care in large first-class hospitals was preliminarily shown.However,there are still some limitations in this study.first of all,although this study describes the symptom control,shared decision-making,comfort care and other contents involved in the palliative care co-management model,it fails to use quantitative objective indicators to show the effectiveness of the co-management model.Secondly,due to the limited consultation capacity,the sample size of patients receiving palliative care in our hospital is still relatively small.Therefore,this study did not set up a control group,and did not compare the effect of care for patients receiving and not receiving co-management.in the future,more detailed objective indicators will be used to evaluate the effect of palliative care co-management model,and to explore its differences with the traditional model,so as to promote its popularization and application in clinical practice。
To sum up,the results of this study show that the palliative care co-management model can alleviate the pain of end-stage patients and provide support for their families and the original medical team,which is worthy of further promotion in Grade 3A hospitals。
conflicts of interest All authors declare no Conflicts of Interest
Author's contribution statement Geng Ruixuan:Research Design,Data analysis,Paper writing;Zheng Ying:Study design,data collection;Chenchen Sun,Xi Zeng,Hongyan Fang,Wenqian Zhan,yuanfeng Yu,Qin Yang,and Xiaoyan Dai:data collection;Xiaohong Ning:Research Topic,Research design,paper Revision

References

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