“PASS”- Psychosocial Assessment & Sustainable Support in End of Life (EOL) care in Residential Care Homes of Elderly (RCHE) in United Christian Hospital (UCH)

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Authors (including presenting author) :
Lauw W L (1,2), Lee K Y (1,2), Karn K Y (3), Ng H Y N (1,4), Chan A (1,5)
Affiliation :
(1) Community Geriatric Assessment Team, United Christian Hospital (2) Community Nursing Service, United Christian Hospital (3) Nursing Service Division, United Christian Hospital (4) Palliative Care Unit, Department of Medicine and Geriatrics, United Christian Hospital (5) Kwun Tong District, Social Welfare Department
Introduction :
EOL care program in RCHE was launched since October 2017 in UCH and more than 130 cases were recruited. Community Geriatric Assessment Team (CGAT) nurses using memory booklet designed by UCH CGAT to explore psychosocial aspect of patient and their families. However, nurses found limited resources on handling psychosocial problems identified. These included poor family relationship, caregiver stress and bereavement care. In order to advocate for EOL patients and families, referral system and regular case conference with social worker was established.
Objectives :
(1) To provide one stop outreach psychosocial assessment & support to EOL patient and families. (2) To advocate for patients and families for psychosocial needs.
Methodology :
Psychosocial aspects of patients and/ or families were explored by using 四道人生 ─ 道謝 道歉 道愛 道別as a framework in EOL memory booklet. Patient and/ or families was referred to social worker in any point of care once psychosocial problems were identified. Moreover, social worker joined regular case conference and recruited target cases proactively. Nevertheless, EOL care not ended after patient deceased. CGAT nurses contacted families via phone and sent sympathy card for bereavement care. Family members were referred to social worker for grief support if they have difficulty coping in bereavement.
Result & Outcome :
Total 6 cases and 32 intensive visits with average 60 minutes per visit were delivered by social worker and intervened in any point of EOL care. The visits targeted on unfinished business of patient including rebuild broken family relationship and life review. CGAT nurses and social worker conducted outreach family counselling with self-reflection. Individualized memoirs were also published after life review. For caregiver stress, family members experienced emotional outburst and expressed in scolding or slapping patient. Social worker intervened with counselling and stress management. CGAT nurses also empowered caregivers with caring skill transfer. These allowed families to walk with patient throughout EOL. Nevertheless, family members with strong bonding experienced risk of suicide after patient deceased. Bereavement care was crucial for family members. Counselling was conducted and community social support network was referred. All family members exhibited normal grief after counselling. In conclusion, outreach support for EOL case with complicated psychosocial needs filled gaps in current setting, hence provide holistic care. Peer support group among caregiver will be set up in order to support EOL case in long run. To sum up, CGAT facilitated patient and families to PASS through hard time in life.

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