Community Palliative Care Team Gaia, Local Health Unit of Gaia and Espinho, Vila Nova de Gaia, Portugal.
Faculty of Medicine of University of Coimbra, Coimbra, Portugal.
J Prim Care Community Health. 2024 Jan-Dec;15:21501319241285340. doi: 10.1177/21501319241285340.
INTRODUCTION/OBJECTIVES: Community palliative care support teams specialize in providing at-home care under referral criteria distinct from hospital teams, focusing on functional status, limited benefit from continued hospital specialty care, and increased clinical complexity. This study aimed to assess the quality of referrals and the transition of care to a specialized community palliative care team, emphasizing adherence to established referral criteria.
An observational, longitudinal, retrospective cohort study evaluated clinical health records of patients who received palliative care from a community team in 2023. We evaluated prior multidisciplinary follow-up, basic social support, medication changes made during the team's first consultation, and recurrences to hospital emergency care. The data was collected from the patients' clinical files.
The patient cohort had a mean age of 80.7 years (±11.92), ranging from 31 to 103 years. Males comprised 56.3% of the participants, with a median follow-up time of 32 days. Primary diagnoses included cancer (50%), end-stage organ failure (26%), and neurodegenerative disease (24%). Among the deceased, 85.6% died at home. Patients showed marked changes in psychological support and social rights, as we observed an improvement from 6.8% to 100% ( = .0011) and from 47.1% to 100% ( = .01) in these supports, respectively. We also observed significant changes in pharmacotherapeutic plans, regardless of the referring team. The study observed significant difficulty in recognizing referral criteria for specialized palliative care and defining clinical complexity. Referrals were often delayed, particularly for those previously under hospital care ( = .001). Increased prescription of pro re nata medications significantly correlated with home deaths ( = .021).
Most complex patients can be effectively monitored and die at home, reserving hospital deaths for exceptional cases requiring interventions not possible at home or due to significant caregiver burden. There was no difference in the biopsychosocial approach of patients previously followed by other teams, including hospital palliative care teams, which suggests very different approaches.
介绍/目标：社区姑息治疗支持团队专门根据与医院团队不同的转诊标准提供家庭护理，重点关注功能状态、继续接受医院专科治疗的益处有限以及临床复杂性增加。本研究旨在评估向专门的社区姑息治疗团队转诊的质量以及护理的过渡，重点是遵守既定的转诊标准。
一项观察性、纵向、回顾性队列研究评估了 2023 年接受社区团队姑息治疗的患者的临床健康记录。我们评估了先前的多学科随访、基本社会支持、团队首次咨询期间进行的药物更改以及再次到医院急诊护理的情况。数据来自患者的临床档案。
患者队列的平均年龄为 80.7±11.92 岁，年龄范围为 31 至 103 岁。男性占参与者的 56.3%，中位随访时间为 32 天。主要诊断包括癌症（50%）、终末期器官衰竭（26%）和神经退行性疾病（24%）。在死亡患者中，85.6%在家中死亡。患者在心理支持和社会权利方面表现出明显变化，我们观察到支持从 6.8%到 100%（ = .0011）和从 47.1%到 100%（ = .01）的显著改善。我们还观察到无论转诊团队如何，药物治疗计划都有显著变化。研究观察到识别专门姑息治疗的转诊标准和定义临床复杂性存在显著困难。转诊往往延迟，特别是对于那些以前接受医院治疗的患者（ = .001）。增加开具即释药物与在家中死亡显著相关（ = .021）。
大多数复杂患者可以在家中得到有效监测和死亡，将医院死亡保留给需要在家中不可能进行的干预或由于 caregiver负担过重的特殊情况。以前由其他团队（包括医院姑息治疗团队）随访的患者的生物心理社会方法没有差异，这表明方法非常不同。
