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Transitioning end-of-life care from hospital to the community: case report

23 September 2021
Volume 30 · Issue 17


Palliative/end-of-life care is an integral part of the district nursing service. There is increasing demand for palliative care to be delivered in the community setting. Therefore, there is a need for excellent collaboration between staff in primary and secondary care settings to achieve optimum care for patients. This article critically analyses the care delivered for a palliative patient in the hospital setting and his subsequent transition to the community setting. The importance of effective communication, holistic assessment in palliative care, advance care planning, organisational structures and the socio-cultural aspects of caring for patients at the end of life are discussed. Additionally, the article highlights the impact of substandard assessment and communication and the consequent effect on patients and families.

This article will discuss the end-of-life (EOL) care provision for a patient discharged from an acute trust into the community setting. It will highlight the importance of effective communication between the multidisciplinary team and the associated barriers that can impact patient care. Additionally, the benefits of advance care planning, holistic care and an understanding of how organisational structures can impact care delivery will be explored. Finally, the importance of recognising and addressing socio-cultural issues related to EOL care will be examined.

The beneficial outcomes of clear communication between health professionals in delivering successful palliative care and symptom control were highlighted by Spruyt (2011). This research described effective palliative care as a multi-dynamic professional intervention requiring medical and nursing staff, psychologists and social workers. Spruyt (2011) further reported that good communication, co-ordination and information sharing are paramount for good health outcomes, benefiting patients and their families.

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