Developing primary palliative care

Editor—Murray et al say that community palliative care should be available to more patients, including those with non-malignant disease.¹ We report the reality of achieving community care for patients discharged from a cancer centre.

Data from 2000 consecutive patients referred to a hospital palliative care team were collected prospectively. Outcome was categorised as discharge home (patient's or carer's); transfer to another hospital or nursing home, transfer to specialist palliative care unit, died in Ninewells, or referral back to original medical or surgical team. Performance status, using the palliative performance scale (see bmj.com for details), was determined at referral.²

Altogether 96% had cancer and 4% non-malignant disease. On average, patients were in their late 60s (median 69 years) and able to do little for themselves (median palliative performance score 50%). Thirty five per cent (703) were bedbound all or most of the time, and 38% (755) lived alone.

Thirty one per cent (619) were discharged home, 28% (568) died in Ninewells; and 28% were transferred to another place of care (458 to a hospice, 110 to a district or community hospital or nursing home). Twelve per cent (245) were discharged back to the referring team.

Patients discharged home had a better performance status than those who did not (figure). The probability of getting home with a performance status of 60 or more was better than 1 in two patients (55%; 343/619), but as performance status fell to 40 or less, probability was < 1 in 10 patients (9.5%; 67/703).

Figure 1.

Outcome after referral to specialist palliative care in relation to palliative performance status

Current community palliative care services are not sufficiently funded to offer a serious alternative to acute hospital care for most patients.