Authors (including presenting author) :
LAM M(1), WONG CK(2), CHAN K(1), SIU TS(1), YU KS(4), LAI KM(3), PO MYY(1), SOONG S(4), FAN HC(3), KNG C(2)
Affiliation :
(1) HKEC Community Geriatric Assessment Team, RTSKH (2) Division of Geriatrics, Department of Medicine and Geriatrics, RTSKH (3) Palliative Care Team, Department of Medicine and Geriatrics, RTSKH (4) Palliative Care Team, Department of Clinical Oncology, PYNEH
Introduction :
HKEC CGAT EOL Care Program commenced in 2015 to provide appropriate care options & facilitate a more dignified dying process for patients approaching end of life in RCHEs. After 4 years of implementation & development, care of CGAT EOL patients has been enhanced with appropriate need-based timely services for symptom control and psychosocial care. In view of the similar service provision by other cluster palliative care (PC) teams in RCHEs, collaboration with PC Teams and HKEC CGAT has been explored in 2019. This paper is to illustrate the service collaboration between the teams for caring EOL patients residing in RCHEs under HKEC.
Objectives :
1. To establish communication platform with cluster PC teams for case sharing and streamline outreach EOL support at RCHEs. 2. To develop sustainable service models for caring EOL cases in HKEC CGAT covered RCHEs.
Methodology :
Cluster PC teams selected suitable cases for referral to CGAT EOL care service. Monthly collaboration meeting between CGAT EOL team & cluster PC teams for discussion on the referred cases. Result of the discussed cases were categorized into 3 service models involving different level of services according to the case complexity: i) Takeover cases receiving CGAT doctor & nurse service, with cluster PC teams follow up if needed. ii) Co-care cases receiving both CGAT doctor & cluster PC teams with CGAT nurse service. iii) Dual care cases receiving both CGAT doctor & cluster PC teams, PC home care nurse & CGAT nurse services. After discussion in the collaboration meeting, CGAT nurse assessed the discussed cases & initiated advanced care planning (ACP) discussion with patients & relatives if EOL criteria met. CGAT nurses would then formulate and provide personalized comfort care to the recruited cases.
Result & Outcome :
Since May 2020 till December 2023, total 129 cases were discussed. 120 cases were categorized into takeover & co-care service models in which candidates were suitable for CGAT nurse to assess & initiate ACP discussion. 52.5% cases were recruited into CGAT EOL program. 5% cases moved to other cluster before ACP discussion. 6.7% cases did not meet the EOL criteria such as no close relatives for ACP discussion or cases under guardianship. 20% cases passed away before ACP discussion or family decision. 14% cases refused or not ready to join EOL program. 1.7% cases were recruited into EOL program by PC teams. 2 cases refused CGAT service & preferred to follow up PC teams. Our results showed that the collaboration not only can help cluster PC teams to share case load but also enhance CGAT EOL service and foster interdepartmental communication. For those not recruited into EOL program were still under CGAT doctor and nurse services with intersectoral collaboration with MOSTE.
