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Alias R, Neo YL, Wang L, Sie LZ, Goh HJ, Mohamed Hussein MY, Abdullah H, Wong YP. Fulfilling last wishes: improving the compassionate discharge process. BMJ Open Qual 2024; 13:e002666. [PMID: 39009462 PMCID: PMC11253726 DOI: 10.1136/bmjoq-2023-002666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/29/2024] [Indexed: 07/17/2024] Open
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.
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Affiliation(s)
- Rasidah Alias
- Specialty Nursing, Changi General Hospital, Singapore
| | - Yi Ling Neo
- Specialty Nursing, Changi General Hospital, Singapore
| | - Liyun Wang
- Advanced Practice Nurse Development, Changi General Hospital, Singapore
| | - Long Zhen Sie
- Specialty Nursing, Changi General Hospital, Singapore
| | - Hwee Jin Goh
- Specialty Nursing, Changi General Hospital, Singapore
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Chong PH, Hii I, Yeo ZZ. Real-world challenges when facilitating terminal discharge in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:213-215. [PMID: 38904534 DOI: 10.47102/annals-acadmedsg.202254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
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Aoyanagi M, Shindo Y, Takahashi K. General Ward Nurses' Self-Efficacy, Ethical Behavior, and Practice of Discharge Planning for End-Stage Cancer Patients: Path Analysis. Healthcare (Basel) 2022; 10:1161. [PMID: 35885688 PMCID: PMC9321459 DOI: 10.3390/healthcare10071161] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022] Open
Abstract
General ward nurses play a key role in discharge planning for end-stage cancer patients. It is necessary to assess the factors regarding their practice to promote discharge planning in accordance with end-stage cancer patients' wishes. This study aimed to investigate the relationships between general ward nurses' practice of discharge planning for end-stage cancer patients, self-efficacy, ethical behavior, attitude, knowledge and experience, perceived skills, and perceived barriers. A total of 288 general ward nurses from nine hospitals in a city in Japan completed the questionnaire. Path analysis was conducted to test the hypotheses. The results showed that nurses' self-efficacy, ethical behavior (do-no-harm, do-good), knowledge (experience of attending home care seminars), and perceived skills (assertiveness) were positively and directly related to the practice of discharge planning. Nursing experience and perceived skills (assertiveness) were positively associated with discharge planning practice, while perceived barriers (death discussion) and attitude (degree of leaving it to discharge planning nurses (DPNs)) were negatively associated, with self-efficacy acting as a mediator. Thus, our findings show that it is important to enhance self-efficacy and nursing ethical behavior to improve the practice of discharge planning. Accordingly, education regarding home care, assertive communication skills, death discussion, and ethics is needed for general ward nurses.
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Affiliation(s)
- Michiko Aoyanagi
- Faculty of Health Sciences, Hokkaido University, Sapporo 060-0812, Japan
| | - Yukari Shindo
- Faculty of Health Sciences, Japan Health Care University, Sapporo 062-0053, Japan;
| | - Keita Takahashi
- Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo 060-8648, Japan;
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Isenberg SR, Killackey T, Saunders S, Scott M, Ernecoff NC, Bush SH, Varenbut J, Lovrics E, Stern MA, Hsu AT, Bernstein M, Zimmermann C, Wentlandt K, Mahtani R. "Going Home [Is] Just a Feel-Good Idea With No Structure": A Qualitative Exploration of Patient and Family Caregiver Needs When Transitioning From Hospital to Home in Palliative Care. J Pain Symptom Manage 2021; 62:e9-e19. [PMID: 33631330 DOI: 10.1016/j.jpainsymman.2021.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Hospital-to-home transitions, particularly at the end of life, can be challenging for patients and their family caregivers. Therefore, there is a need to better understand gaps in expectations and experiences of these transitions. Theory can inform the creation of an intervention aimed at improving the hospital-to-home transition. OBJECTIVES 1) Explore patients' and caregivers' expectations and subsequent experiences of the hospital-to-home transition while receiving palliative care, and 2) build a substantive grounded theory to enhance the understanding of hospital-to-home transitions from the patient and caregiver perspective. METHODS Longitudinal, prospective qualitative study with semistructured interviews at hospital discharge and three to four weeks after discharge home. We recruited adults receiving inpatient palliative care who were being discharged to home-based palliative care, and their family caregivers from two academic health centers in Toronto, Canada. Thirty-nine participants: 18 patients, 7 caregivers, and 7 patient-caregiver dyads participated. We conducted 52 interviews. We conducted a grounded theory qualitative study. RESULTS Through examining the expectations and subsequent experiences of the transition, and exploring the gaps between them, we identified various transitions needs: health and well-being needs, and practical needs (i.e., transportation, setting up the home for care, care providers in the home). Several enablers and disablers modified the likelihood of needs being met (e.g., caregiver role, education on symptom management, uncertainty, financial resources). CONCLUSION Our substantive grounded theory highlighted potentially measurable constructs that can be further tested. Future interventions should target the enablers/disablers to ensure health and well-being and practical needs are met in the transition.
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Affiliation(s)
- Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Stephanie Saunders
- Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, School of Epidemiology and Public Health, Ottawa, Canada
| | - Natalie C Ernecoff
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Canada
| | - Jaymie Varenbut
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Canada
| | - Emily Lovrics
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Canada
| | | | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, Department of Family Medicine, Ottawa, Canada
| | - Mark Bernstein
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Kirsten Wentlandt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Canada
| | - Ramona Mahtani
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada
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Killackey T, Lovrics E, Saunders S, Isenberg SR. Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers. Palliat Med 2020; 34:1316-1331. [PMID: 32772787 DOI: 10.1177/0269216320947601] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions. AIM The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings. DESIGN A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662. DATA SOURCES We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes. RESULTS Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home. CONCLUSION This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.
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Affiliation(s)
- Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Emily Lovrics
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Stephanie Saunders
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Lundereng ED, Dihle A, Steindal SA. Nurses' experiences and perspectives on collaborative discharge planning when patients receiving palliative care for cancer are discharged home from hospitals. J Clin Nurs 2020; 29:3382-3391. [PMID: 32533726 DOI: 10.1111/jocn.15371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 05/03/2020] [Accepted: 05/24/2020] [Indexed: 01/24/2023]
Abstract
AIMS AND OBJECTIVES To explore nurses' experiences and perspectives on discharge collaboration when patients receiving palliative care for cancer are discharged home from hospitals. BACKGROUND Patients receiving palliative care for cancer experience multiple transitions between the hospital and their home. Poor discharge collaboration is a major cause of preventable hospital readmissions. Collaborative discharge planning could improve the care for these patients outside the hospital setting. Previous research has mostly been conducted in noncancer populations. Further research regarding both home care nurses' and hospital nurses' perspectives on care transitions is required. DESIGN A qualitative study with descriptive and explorative design. METHODS Data were collected through 10 individual, semi-structured interviews of nurses working at two oncology wards at a university hospital and home care services in four municipalities within the hospital's catchment area. Data were analysed using systematic text condensation. COREQ guidelines were adhered to in the reporting of this study. RESULTS Three categories emerged from the data analysis: lack of familiarity and different perceptions lead to distrust; inefficient communication creates a need for informal collaboration; and delayed discharge planning challenges collaboration. CONCLUSIONS The nurses lacked an understanding of each other's work situation, which created distrust, misunderstandings and misconceptions regarding each other's abilities to care for the patient. This led to inefficient communication, relying on individual knowledge, informal communication and personal networking. Delays in the discharge planning resulted in poorly prepared discharges often lacking necessary equipment and documentation. RELEVANCE TO CLINICAL PRACTICE To improve the care of patients receiving palliative care for cancer outside the hospital setting, better communication is a key factor to promote confidence and understanding between nurses working in different settings of health care.
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Affiliation(s)
- Elias David Lundereng
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,Palliative treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Alfhild Dihle
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
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Elmstedt S, Mogensen H, Hallmans DE, Tavelin B, Lundström S, Lindskog M. Cancer patients hospitalised in the last week of life risk insufficient care quality - a population-based study from the Swedish Register of Palliative Care. Acta Oncol 2019; 58:432-438. [PMID: 30633611 DOI: 10.1080/0284186x.2018.1556802] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND One-quarter of all cancer deaths in Sweden occur in hospitals. If the place of death affects the quality of end-of-life (EOL) is largely unknown. METHODS This population-based, retrospective study included all adults cancer deaths reported to the Swedish Register of Palliative Care in 2011-2013 (N = 41,729). Hospital deaths were compared to deaths occurring in general or specialised palliative care, or in nursing homes with respect to care quality indicators in the last week of life. Odds ratios (OR) with 95% confidence intervals (CI) were calculated with specialised palliative home care as reference. RESULTS Preferred place of death was unknown for 63% of hospitalised patients and consistent with the actual place of death in 25% compared to 97% in palliative home care. Hospitalised patients were less likely to be informed when death was imminent (OR: 0.3; CI: 0.28-0.33) as were their families (OR: 0.51; CI: 0.46-0.57). Validated screening tools were less often used in hospitals for assessment of pain (OR: 0.32; CI: 0.30-0.34) or other symptoms (OR: 0.31; CI: 0.28-0.34) despite similar levels of EOL symptoms. Prescriptions of as needed drugs against anxiety (OR: 0.27; CI: 0.24-0.30), nausea (OR: 0.19; CI: 0.17-0.21), or pulmonary secretions (OR: 0.29; CI: 0.26-0.32) were less prevalent in hospitals. Bereavement support was offered after 57% of hospital deaths compared to 87-97% in palliative care units and 72% in nursing homes. CONCLUSIONS Dying in hospital was associated with inferior end-of-life care quality among cancer patients in Sweden.
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Affiliation(s)
- Sixten Elmstedt
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
| | - Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dan-Erik Hallmans
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
| | - Björn Tavelin
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Staffan Lundström
- Stockholms Sjukhem Foundation and Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Lindskog
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
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Wahid AS, Sayma M, Jamshaid S, Kerwat D, Oyewole F, Saleh D, Ahmed A, Cox B, Perry C, Payne S. Barriers and facilitators influencing death at home: A meta-ethnography. Palliat Med 2018; 32:314-328. [PMID: 28604232 DOI: 10.1177/0269216317713427] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach. AIM To identify and understand the barriers and facilitators influencing death at home. DESIGN Meta-ethnography. DATA SOURCES The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis. RESULTS A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication. CONCLUSION Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services.
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Affiliation(s)
- Abdul Samad Wahid
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Meelad Sayma
- 2 Imperial College Business School, London, UK.,3 Peninsula College of Medicine & Dentistry, Plymouth, UK
| | - Shiraz Jamshaid
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Doa'a Kerwat
- 2 Imperial College Business School, London, UK.,4 Bart's and the London School of Medicine and Dentistry, London, UK
| | - Folashade Oyewole
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Dina Saleh
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Aaniya Ahmed
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Benita Cox
- 2 Imperial College Business School, London, UK
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10
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Radha Krishna LK, Murugam V, Quah DSC. The practice of terminal discharge: Is it euthanasia by stealth? Nurs Ethics 2017; 25:1030-1040. [DOI: 10.1177/0969733016687155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
‘Terminal discharges’ are carried out in Singapore for patients who wish to die at home. However, if due diligence is not exercised, parallels may be drawn with euthanasia. We present a theoretical discussion beginning with the definition of terminal discharges and the reasons why they are carried out in Singapore. By considering the intention behind terminal discharges and utilising a multidisciplinary team to deliberate on the clinical, social and ethical intricacies with a patient- and context-specific approach, euthanasia is avoided. It is hoped that this will provide a platform for professionals in palliative medicine to negotiate challenging issues when arranging a terminal discharge, so as to avoid the pitfall of committing euthanasia in a country such as Singapore where euthanasia is illegal. It is hoped that a set of guidelines for terminal discharges may someday be realised to assist professionals in Singapore and around the world.
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Tan YY, Xu ZZ, Pang GSY, Qu L, Xu Y, Zhang AM, Neo PSH. Facilitating terminal discharge: fulfilling the hospitalised patient's wish for home death in the final hours. Int J Palliat Nurs 2016; 22:541-548. [DOI: 10.12968/ijpn.2016.22.11.541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yung Ying Tan
- Assistant Nurse Clinician, Division of Palliative Medicine, National Cancer Centre Singapore (NCCS), Singapore
| | - Zhi Zhen Xu
- Senior Nurse Clinician, Advance Practice Nurse, Division of Palliative Medicine, NCCS, Singapore
| | - Grace SY Pang
- Senior Manager, Home First Group, Agency for Integrated Care, Singapore
| | - Limin Qu
- Senior Research Coordinator, Division of Palliative Medicine, NCCS, Singapore
| | - Yi Xu
- Nurse Clinician, Department of Nursing, Singapore General Hospital, Singapore
| | - Ai Min Zhang
- Nurse Clinician, Department of Nursing, Singapore General Hospital, Singapore
| | - Patricia SH Neo
- Senior Consultant, Division of Palliative Medicine, NCCS, Singapore
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