Fulfilling last wishes: improving the compassionate discharge process

Abstract

Background

Compassionate discharges (ComD), commonly known as rapid discharges, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at their place of choice—usually in their own home. Challenges abound in this time-sensitive setting when multiple parties must work together to prepare medically unstable patients for discharge, yet healthcare staff are largely unaware of the process, resulting in delays.

Methods

Process mapping, an Ishikawa diagram and a Pareto chart were used to identify barriers, which included timely acquisition of home equipment and medication and poor communication among stakeholders. In May 2020, the Quality Improvement (QI) team embarked on a pilot project to reduce family caregiver anxiety and delays in the ComD process while maintaining a success rate above 90% over a 12-month period.

Interventions

Three Plan-Do-Study-Act (PDSA) cycles were used to refine a ComD resource package that was developed; this consisted of a checklist, a kit and caregiver resources. This was to support nurses, doctors and families during this difficult and emotional transition. Items in the ComD resource package were revised iteratively based on user feedback, with further data collected to measure its usefulness.

Results

The 12-month ComD success rate over 3 PDSA cycles were 88.9%, 94.2% and 96.7%, respectively, after each cycle. There was a consistent reduction in the level of family anxiety before and after caregiver training and resources. Reasons for failed ComD included acute clinical deterioration or delays in obtaining home oxygen support.

Conclusion

The ComD resource package allowed collaborative work across different disciplines, strengthening the safety and utility of ComD and allowing patients to die in their place of choice. These are ubiquitous across settings; this QI problem is thus relevant beyond our local institution.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Most hospitalised patients at the end of life prefer to die at home. This results in rapid discharges at the end of life to allow death in a place of choice.

• Barriers to facilitating rapid discharges include timely acquisition of home equipment and medication, transport and poor communication across settings—these may result in failed discharges whereby patients who wish to die at home do so in a hospital instead.

WHAT THIS STUDY ADDS

• This study explores how using a resource package reduces delays and improves the chances of successful rapid discharges at the end of life, which is also known as ‘compassionate discharge’ in Singapore.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Having a customised resource package ingrained within a discharge workflow provides guidance to healthcare professionals involved in compassionate discharges, relieves family anxiety, reduces delays and maximises the chances of dying patients going home on time to pass on in their preferred place of death.

• This is crucial in reducing hospital deaths as a key quality indicator of end-of-life care.

Introduction

Problem description

Compassionate discharges (ComD), commonly known as ‘rapid discharges’ in literature, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at their place of choice.¹ It is a complex process requiring the involvement of multiple stakeholders (the inpatient healthcare team, family caregivers, ambulance staff and the palliative home care team in the community).² Such end-of-life discharges are increasingly common worldwide, particularly in developed countries to honour patients’ preferences to die at home.³

There is vital cultural and religious significance to dying at home; it allows one privacy to carry out desired end-of-life rituals that may not be possible in the hospital space. For example, some Chinese Buddhists prefer not to let the deceased’s body be touched for up to 8 hours after death to facilitate the correct departure of the soul from the physical body.⁴ Muslims prefer to die at home with family around them for confession of sins, seeking forgiveness, reconciliation and for different members of the family to take turns to read the Quran and make supplications to God at the bedside.⁵ Singapore is a multiracial society with one of the highest religious diversities in the world,⁶ such practices are common at the end of life here. Cultural taboos about death and dying make early discussions about end-of-life care preferences challenging⁷ often the request to return home to die happens when death is imminent. Such a decision cannot be preplanned, but a rapid response is necessary.^{1 3}

Available knowledge

A local ‘death attitude survey’ done by Lien Foundation in 2014 revealed that 77% of Singaporeans wish to die at home.⁸ Similarly, in worldwide surveys, most people prefer to die at home⁹ surrounded by loved ones—this is perceived as a ‘good death’.^{9 10} However, as of 2022, 62.1% of Singaporeans died in hospitals.⁸ Among the top reasons quoted by Singapore’s Health Minister were challenging discharge processes and protocols (formerly known as Terminal Discharge), inadequate caregiver preparedness¹¹ and the high cost of care¹⁰—50% of one’s total lifetime healthcare cost amounting to SGD $61,680, on average, is incurred in a person’s last year of life and SGD $8,350, on average, is spent in one’s last 3 months of life.^{11 12} With home palliative care involvement, the chances of dying at home are higher and reduces healthcare cost by 10%.¹² It also reduces the total healthcare cost, resource utilisation and improves patient and caregiver outcomes.¹³

Internationally, common barriers include difficulty obtaining equipment and care provision, limited communication across settings and delays in obtaining medication and transport.^{14 15} These may result in failed discharges whereby patients who wish to die at home do so in a hospital instead. The rarity of ComD makes it difficult for doctors and nurses to recall the process whenever the need arises.11,13 Given the end-of-life nature of a ComD, family caregivers feel uncertain, yet face a lack of psychological support.¹⁶ Challenges such as the coordination of logistics between acute and community settings, lack of awareness of the process and delays in discharge³ are ubiquitous across settings, making this QI problem relevant beyond our local institution in Singapore.

Solutions that hospitals worldwide have developed include pathways¹⁷ or checklists,¹⁸ coordination centres, a telephone advice line,¹⁹ physical and online resources for healthcare professionals and the family and involvement of a specialist team like palliative care.18,20 Effective communication across all stakeholders and clear documentation have been demonstrated to result in a smoother transition of care from hospital to home.²⁰

Rationale

The gap to be addressed appears to be an intervention that reduces delays and improves the chances of successful rapid discharges at the end of life, or ‘ComD’ as it is known in Singapore. At the start of 2020, hospital visitation restrictions imposed during the COVID-19 pandemic to limit viral transmission increased the number of requests for ComD.²¹ This added to the workload of overburdened healthcare staff during the pandemic.²¹ The stress of the pandemic on the healthcare system^{17 18} further complicated the barriers to ComD described above, which drove us to redesign the ComD process to reduce the burden on healthcare staff and family caregivers. In May 2022, Ministry of Health (MOH), together with the National Strategy for Palliative Care review workgroup,²² announced a work plan to make palliative care a national priority.¹ One of its priorities was to decrease the number of hospital deaths by 10% in the next 5 years.¹ With the push from MOH and thus, increased public awareness, we anticipate a rise in requests for ComD in the near future.

Traditionally, most of the ComD that have occurred in our public hospitals require the support of the consultative palliative care team. However, the projected rise in the number of ComD is likely to overwhelm this specialist team. General medical and nursing staff will need to be trained to facilitate ComD, with initial handholding from the palliative care team. Our QI intervention is of utmost importance to streamline the ComD process by developing a resource package consisting of a checklist, kit and caregiver resources. This resource package can be easily replicable and localised to other settings.

Specific aim

Eight specialist palliative care nurses formed a QI team and overhauled the existing ComD process by developing a ComD resource package to improve facilitation by interdisciplinary teams for patients’ smooth and timely transition home to die. The project aimed to reduce caregiver anxiety and delays in the ComD process as well as to sustain a 12-month success rate above 90%.

Methods

Context

This QI project took place in a large tertiary public hospital in the eastern region of Singapore, serving over 1 million people with around 1000 beds.²³ ComD activation involves various tasks happening simultaneously. Primary doctors coordinate home palliative care, prescribe medications and discharge documents while managing other acutely ill patients. Pharmacists ensure safe and timely dispensing of opioids. Ward nurses provide caregiver training (CGT) on tasks like injectables and diaper changes, arrange oxygen and transport and communicate discharge instructions. Palliative care nurses assist with discharge medications (prefills or infusor), often leading the process to support the primary doctor and ward nurse. The goal is for the patient to reach home without rapid deterioration.

The QI team, who are themselves specialist palliative care nurses with experience in facilitating ComD, conducted an analysis to understand the microsystem of ComD work processes using flowcharts. An Ishikawa diagram was used to identify major factors affecting ComD.²⁴ Brainstorming sessions identified 27 root causes of delays.²⁴ To prioritise the root causes to focus on, the QI team had two rounds of voting²⁴—in the first round, each member was allowed four votes, of which only one vote could be cast for each cause. The second round of voting allowed six votes per member—members were then allowed multiple votes on one cause if they felt strongly about it. This led to the final nine identified causes of delays (online supplemental material 1). The chosen themes were (1) doctors and nurses’ knowledge deficit of ComD, (2) family caregivers’ fear of ‘hurting’ their loved one when injecting medications and (3) family members’ anxiety in managing end-of-life issues.

Interventions

The various components of the ComD resource package were designed to address the delays identified. To reduce time spent gathering consumables, the QI team worked with a representative from the Pharmacy department to develop a process whereby a ‘ComD kit’ of consumables could be ‘ordered’ when a doctor prescribes discharge medications for ComD. This was a small box (23×9×6 cm) containing prepacked paraphernalia for administering parenteral medications that family caregivers or home hospice nurses can quickly use in the home setting for patient care (see figure 1A). Family caregivers could collect the discharge medications along with the kit at the hospital pharmacy before taking the patient home. To ease logistical arrangements, the QI team collaborated with the hospital’s discharge coordinators, known as ‘Patient Navigators’. They are nurses who are well informed about community resources and can assist the ward nurses in arranging medical equipment and transport.

Figure 1. The ComD resource package consisting of (A) ComD kit with coloured labels, (B) medication chart for caregivers, (C) step-by-step pictorial guide to teach caregivers how to administer medications subcutaneously, (D) Saying Goodbye brochure to guide caregivers on symptoms of dying and post-death procedures and (E) a ComD checklist for doctors and nurses. ComD, compassionate discharges.

The QI team sought to simplify information given to caregivers regarding medications needed for symptom control to reduce caregiver anxiety. To enable ease of use, coloured labels pasted on the medications were paired with the colour-coded medication charts issued to family caregivers (see figure 1B). Caregiver resources such as pictorial guides for administering subcutaneous medications (figure 1C) and a ‘Saying Goodbye’ pamphlet with information on signs of dying and postdeath procedures (figure 1D) were developed for caregiver training.

Finally, a ComD checklist was created as a simple two-page document combining the doctor and nurse roles, which also acts as a guide to the ComD process (refer to figure 1E and online supplemental material 2). It also documents the details involved in the ComD that can be used in communication with the home hospice team. The input of palliative care specialists was sought regarding the doctor’s role, including a standardised ComD medication list that primary care doctors could prescribe for most ComD patients. The combined checklist enables both the doctor and the nurse to follow through the instructions at a glance, so as to act quickly in tandem for the common goal of fulfilling a patient’s wish to die at home.

The ComD checklist and caregiver resources were placed in an easily retrievable location on the organisation’s intranet and shared with nursing managers, who then disseminated the information to the staff in their departments.

Study of the interventions

The first Plan-Do-Study-Act (PDSA)²⁴ cycle was implemented in May 2020 with the entire ComD resource package consisting of the ComD checklist, kit and caregiver resources. This cycle aimed to evaluate the usefulness of the resource package in facilitating a ComD. The ComD resource package was used for every ComD referred to the inpatient palliative care team. When a ComD is initiated, the palliative care nurse would take the checklist and caregiver resources to the ward, explaining to the nurse-in-charge how to use them.

To assess the impact of the intervention, we collected feedback from identified stakeholders as a process measure (refer to table 1 for feedback collated during PDSA cycles 1 and 2) to improve the ComD resources. After a successful discharge, one of our QI team members would get feedback from the ward nurse on the usefulness of the checklist through a 5 minute online survey (online supplemental material 3) that could be completed using a mobile phone by scanning a QR code. The survey tool used was FormSG,²⁵ a form builder tool that enables public officers to create secure, digital government forms. Home palliative care nurses were likewise asked to provide feedback on the ComD kit within one week after patients had gone home, using a similar survey. However, we did not always get a complete response on these surveys.

Table 1. PDSA cycle 1 and 2—feedback from inpatient nurses, inpatient doctors, family caregivers and home hospice nurses after using the ComD resource package.

PDSA cycle	Identified stakeholders	Example of positive feedback	Example of negative feedback	Suggestions provided
PDSA cycle 1	Feedback on ComD checklist
	Inpatient nurses (n=30)	✔ Helped as guide on the process	✘ Too wordy	★ Reduce the word count
	Inpatient doctors (n=5)	✔ Helped as a guide	✘ Unsure how many ampoules of drugs to prescribe	★ Recommend a standard for number of ampoules
	Feedback on caregiver resources and ComD Kit
	Family caregivers (n=10)	✔ Reported reduced anxiety with available resources✔ Colour codes were helpful✔ Pictorial resources are easy to follow	✘ Overwhelmed with information✘ Some felt anxious reading so many words	★ Create video resources for ease of following steps of procedure★ Provide Saying Goodbye brochure in other languages for non-English-speaking caregivers
	Home palliative care nurses  (n=10)	✔ Very helpful—helps to relieve caregiver stress✔ Presence of pre-filled syringes ease administration of medication by family✔ Family felt less anxious having the ComD kit on hand, while awaiting the arrival of the home care team✔ Allows family to help the patient achieve a peaceful death even before the home care team arrives	✘ Insufficient stoppers provided in the ComD kit—hard to purchase in the community setting	★ Supply sufficient numbers of stoppers based on the number of syringes provided
PDSA cycle 2	Feedback on ComD checklist
	Inpatient nurses+specialist palliative care nurses (n=32)	✔ Better presentation of information✔ Helped as a guide on the process	✘ Still too wordy✘ Difficulty locating ambulance and oxygen vendor contacts	★ Use of checkboxes for easy checkoffs★ Separation of the doctor’s and nurse’s roles into two columns to avoid confusion★ Use of broad categories for a visual overview of the ComD process★ Include valid ambulance and vendor contact numbers for ease of access
	Inpatient doctors (n=5)	✔ Helped as a guide	✔ Uncertain of communication process with community partners✘ Uncertain how to prescribe controlled drugs for use at home	★ Provide guidance on these processes★ Indicate specifically memos required for each community partner (eg, home palliative care team, general practitioner, etc)
	Feedback on caregiver resources and ComD Kit
	Family caregivers (n=15)	✔ Reported reduced anxiety with availability of resources✔ Colour codes were helpful✔ Pictorial resources are easy to follow	✔ Too many papers to keep track of✔ Language barrier for non-English-speaking caregivers—do not understand caregiver medication chart in English✘ Uncertain what to do with unused medications	★ Requested for electronic copy of Saying Goodbye brochure to be available on the internet for ease of download★ Translate medication chart into other commonly spoken languages, for example, Mandarin, Malay★ Provide instructions for disposal of unused controlled drugs/medications
	Home palliative care nurses (n=10)	✔ Helps relieve caregiver stress✔ Family was observed to be more confident in administering medications to the patient before the arrival of the home care team	✘ Number of combi stoppers still insufficient✘ Challenging for caregivers to use terumo tip syringes due to their tendency to ‘pop’ out of the cannula	★ Supply more combi stoppers★ Change luer-slip syringes to luer-lock syringes to maximise medication administration

The colours were included to provide ease of visualisation. Orange cells are for PDSA cycle 1, Blue cells are for PDSA cycle 2.

ComDcompassionate dischargesPDSAPlan-Do-Study-Act

Family caregivers were invited to provide informal verbal feedback on caregiver resources after they had undergone CGT—this was not always possible, as it was determined by the emotional state of the family member at the time of discharge. Some felt overwhelmed by all the information they had to quickly learn on top of CGT; in this case, we would not request for feedback. The feedback obtained was collated in a Microsoft Word document by the QI team.

Measures

A ‘successful ComD’ refers to when a patient has been discharged promptly from the hospital to die at home. Data collection started in 2018, averaging 24 ComD cases annually from January 2018 to December 2019. The 12-month success rate of ComD was used to measure the impact of a resource package. After the second PDSA cycle from May 2021 to Apr 2022, delays in obtaining home equipment, discharge documents and medications were identified, resulting in two patients (3.3%) dying in the hospital before going home. Cases where patients could not go home due to delays were termed ‘failed ComD’. No data on failed ComD were collected in the baseline measurement, so there is no pre-QI success rate available.

An ‘unsuccessful ComD’ is when the workflow process is initiated but the patient does not get to go home due to reasons unrelated to the workflow. This often occurred when a family caregiver changed their mind and decided for the patient to remain in the hospital until the time of death. We spoke with the nurses who facilitated the ComD to determine if any delays came about in the process. Subsequently we collected data on the numbers of unsuccessful and failed ComD as well as the reasons for these occurrences.

In PDSA cycle 3, we included utilisation rate of the ComD resource package as a process measure and level of family caregiver anxiety as a balance measure. A dedicated palliative care nurse in charge of the patient for ComD would assess the level of family caregiver anxiety based on a 4-point Likert scale before and after CGT, where 1—not anxious at all, 2—a little anxious, 3—anxious, 4—very anxious. The Likert scale was adopted as it is able to map individuals’ perceptions and attitudes, which is difficult to measure directly.²⁶ It also allows for a quick assessment of the relative’s anxiety, as CGT often took place within a time-sensitive situation, and it is easy to understand.²⁶ Before the CGT, the palliative care nurse would ask the family caregiver to rate the level of their anxiety at that point in time, for example, ‘how anxious do you feel right now about providing caregiving?’ After the CGT, the same nurse would then ask the family caregiver to rate the level of their anxiety.

We have found that, in some situations, the main family caregiver is often not keen to share too much about themselves or feelings either as their minds are focused on completing the myriad of tasks at hand to help their loved ones get home in time. In situations where the family relative was not able to rate their level of anxiety on a 4-point scale, the nurse would perform a subjective assessment. through anecdotal-observation of their coping during the CGT.²⁷

The purpose of these measures was to evaluate if utilisation of the ComD resource package could achieve the desired outcome of a ComD success rate above 90% and allay family anxiety.

Analysis

Descriptive analysis of data was done using Microsoft Excel. We had not yet collected the reasons for failed ComDs prior to the third PDSA cycle, hence there was no circumstantial data for those cases. The QI team gathered once a month to look through the data to ensure data accuracy and remove discrepancies. At our monthly meeting, the QI team would look at the trends of the data to identify problem areas (such as continuing sources of delay).

Each ComD that did not result in success was discussed and debriefed by the QI team. This ensured accurate labelling of either a ‘failed ComD’ or an ‘unsuccessful ComD’. The discussion also provided insight into how the process could be further improved, with brainstorming of solutions that can be quickly implemented to minimise disruptions to the discharge process.

Ethical considerations

This work is deemed to be an improvement study and not a study on human subjects, therefore local policy excludes this from requiring ethical approval.

Results

A total of three PDSA cycles were completed to measure the test of change.²⁴ Testing of change ideas of each cycle was based on learning from failure and successes of cases that were referred to the palliative team for ComD.

PDSA cycle 1 (May 2020—April 2021)

PDSA 1 focused on initial implementation and feedback collection. In this cycle, we learnt that it was impossible to collect complete feedback data to guide in the development of our resources due to the sensitive nature of a ComD. The ComD checklist was revised 10 times based on user feedback during this cycle. Overall feedback from the identified stakeholders was largely positive, leading to the second PDSA cycle.

PDSA cycle 2 (May 2021—April 2022)

PDSA 2 demonstrated a continuous effort through adaptation and improvement of the ComD resources based on user input and experiences by refining tools and resources. Stakeholders’ feedback was still used as a process measure (table 1). Based on feedback from ward nurses and specialist palliative care nurses, the ComD checklist was revised another 16 times. Improvements in subsequent iterations included (1) use of checkboxes for easy check-offs; (2) separation of the doctor’s and nurse’s roles into two columns to avoid confusion; (3) use of broad categories for a visual overview of the ComD process; (4) inclusion of valid ambulance and vendor contact numbers for ease of access. The caregiver medication chart was translated into other common languages spoken in Singapore (Mandarin and Malay) after feedback from different family caregivers. Information on disposal of controlled drugs after a patient’s demise was included in the caregiver resources.

PDSA cycle 3 (May 2022—April 2023)

PDSA 3 focused on enhancing the existing ComD process and workflow. To maximise the chances of a successful ComD, the third PDSA cycle aimed to act quickly on findings observed during cycle 2. It was discovered that the 10 L/min oxygen concentrator was the most frequently obtained home equipment for ComD; the QI team then rearranged the private vendors list such that vendors that could supply up to 10 L/min of oxygen were placed at the top of the list. Delays in obtaining discharge medications were sometimes due to the cumbersome task of filling in manual prescription forms for controlled drugs—junior doctors, often tasked to facilitate a ComD, were frequently found to be unfamiliar with this. The QI team circumvented this by printing out a sample of a completed form and taking it to every ComD. We also highlighted this finding to the pharmacy department; they are now amid digitalising the prescription process of controlled drugs for ease of ordering medication. ComD references were also made available in the hospital intranet.

Outcome, process and balance measures

During the COVID-19 pandemic, visitation restrictions led to requests for ComD to allow families to be together at home. After the first PDSA cycle from May 2020 to April 2021, the ComD success rate was 88.9% (n=16). Postpandemic awareness of ComD increased, with success rates of 94.2% (n=49) after the second PDSA cycle from May 2021 to Apr 2022 and 96.7% (n=59) after the third PDSA cycle from May 2022 to April 2023. Unsuccessful ComD cases were excluded as they were unrelated to the process. In the third cycle, 61 family caregivers’ anxiety levels were assessed before and after CGT, showing a consistent reduction from a mean of 3.90 before to 2.72 after using caregiver resources from the ComD package for CGT.

After the team debrief, it was determined that the reasons for the two failed ComD after the third PDSA cycle from May 2022–April 2023 were due to delays in obtaining home equipment and discharge documents.

In the period from May 2022 to April 2023 after PDSA cycle 3, there were 19 unsuccessful ComD cases. Reasons included patient’s rapid deterioration despite a smooth process (n=10), family caregiver changing their mind (n=7) and patient being unsuitable for ComD due to medical reasons (n=2).

Following the third PDSA cycle, the ComD resource package was well utilised. The ComD checklist was used for all cases (n=61), caregiver resources for 67.2% (n=41) of cases and the ComD kit for 57.4% (n=35) of cases. Caregiver training was sometimes not provided if the patient’s condition rapidly worsened, with the home hospice team conducting training at the patient’s home. The ComD kit was not supplied when the patient is imminently dying, prioritising discharge speed. The home hospice team would then take over to complete any pending tasks.

Discussion

Summary

A resource package consisting of a checklist, kit and caregiver resources was developed as an intervention to be used for all ComD. With this intervention, we achieved our aim to reduce family caregiver anxiety, address sources of delay and maintain the success rate of ComD above 90% within the 12-month period after the second and third PDSA cycles, despite rising numbers of ComD requests (see figure 2).

Figure 2. Number of failed and successful ComD from 2019 to May 2023, categorised according to each 12-month post-intervention period after the respective PDSA cycles. A successful ComD is defined as when the patient is discharged in a timely manner from the hospital to go home to pass on. A failed ComD is when the patient dies in the hospital despite initiating the workflow, with the failure potentially due to the workflow (eg, delays). An unsuccessful ComD is when the patient is referred to the palliative consult team for a ComD but does not proceed with it—usually due to reasons unrelated to the workflow. ComD, compassionate discharges; PDSA, Plan-Do-Study-Act.

In line with the MOH work plan, we are confident that our ComD resource package smoothens the discharge process and reduces family anxiety. With an improved process, the larger body of medical and nursing staff can handle the anticipated increase in ComD independently and help to achieve patient’s wishes to die at home. This would free up the specialist palliative care nurses to focus on other specialty needs.

Interpretation

Similar to studies done in other parts of the world, our data demonstrate that having physical and online resources along with palliative team support6,8 improves the success of a ComD. Additionally, the ComD resource package we developed streamlines the ComD process by targeting identified delays and facilitating coordination among different stakeholders. This enables fulfilment of the patient’s preferred place of death, as shown by the high success rate.

This intervention impacts patients and family caregivers by increasing the success of patients who wish for it to die at home. Primarily it presents ComD as a package with a preset list of instructions and expectations, which acts as guidance to family caregivers. This helps them feel more in control, in an urgent situation that is escalating quickly. Patients, too, feel reassured when they know they will be going home. The intervention has impact on the healthcare system in general—the coordination of resources and maintaining a working relationship between inpatient and home palliative care providers allow for more seamless transitions of care. Our intervention is also in line with MOH goals for increased numbers of ComD to promote good palliative care and reduce hospital utilisation in the last days of life.

Working in a diverse setting has allowed us to meet different religious and cultural preferences. An example of how this has been done is in the ComD package being customised accordingly, as evidenced by the multilingual medication chart for caregivers. Identifying appropriate data parameters and collecting data continuously gave us a real-time picture of the obstacles in the ComD process, which enabled us to remedy issues immediately before the next ComD occurred, to improve the chances of success.

Limitations

This project was a rapid response by specialist palliative care nurses (eventually forming the QI team) to increasingly frequent requests for ComD during the pandemic,²⁸ hence the lack of baseline data that typically informs a QI project—this led to some difficulty in comparing outcomes after the QI intervention was implemented. The Ishikawa diagram and Pareto chart was not used for subsequent PDSA cycles 2 and 3 as changes to the resources did not warrant a major overhaul that required a review of its root causes. Over time as we learnt more about QI tools, we came up with the interventions in a more structured and cyclical PDSA approach.

Identifying appropriate data parameters and collecting data continuously gave us a real-time picture of the obstacles in the ComD process, which enabled us to remedy issues immediately before the next ComD occurred, to improve the chances of success. There were many other ‘mini’ PDSA cycles in between the main cycles to finetune our work processes, which led to many iterations of our planned resources.

Data variables could have been better quantified, such as the assessment of anxiety based on a 4-point Likert scale, which may not be sufficient to assess caregiver distress fully. A proper scale to assess this could be the Hospital Anxiety and Depression Scale (HADS).²⁹ However, this is lengthy and hard to implement in view of ComD urgency. Family caregivers who do not speak English are unable to complete the HADS. It was also difficult to obtain feedback from family caregivers during the ComD process due to the sensitive and emotional nature of imminent death.³⁰

It is acknowledged that the success rate of ComD cannot be attributed to using the ComD resource package alone. Many factors come into play: at which stage an end-of-life discussion is initiated; timely identification of a suitable patient with prognosis within 7 days; clear communication among stakeholders; the availability, preparedness and readiness of the caregiver; symptoms that may be hard to manage at home, and how close a person is to the time of death. These enhancers or barriers may occur while facilitating a ComD, over which we have limited control.

Conclusions

It is well documented in the literature that ‘rapid discharges’ require multiparty collaboration and coordination of resources. Our project team identified and addressed delays in the ComD process using the ComD resource package that we developed, which included a checklist, kit and caregiver resources. These allowed for collaborative work across different disciplines, strengthening the safety and utility of ComD and allowing patients to die in their place of choice.

The reasons uncovered for failed and unsuccessful ComD point to external contextual elements that affect a person’s eventual place of death regardless of preference, providing insight into areas we can focus on to reduce barriers for hospitalised patients wanting to pass on at home.

Sustainability was promoted through: (1) ongoing data collection on factors causing delays and feedback from users of the ComD resources; (2) regular updating of the resources based on analysis of the data collected; (3) an easily accessible ComD resource website that is maintained by the QI team; (4) training conducted to hospital doctors and nurses.

Next steps include improving the caregiver experience, training a pool of ‘ComD champions’ to tap on as and when an urgent ComD occurs, and spreading the change package across the entire institution and beyond.

Data availability statement

No data are available.