Responding urgently to situations of vital distress in the palliative care environment, without the patient leaving his home: that is the challenge of Pallidom. This initiative was launched three years ago in the Paris region. Presentation.
1500.
This is the number of patients who have benefited from the Pallidom system since its establishment on September 6, 2021. This care structure combines the specialties of three medical sectors: emergency, palliative care and home hospitalization. “The starting point for our thinking was based on the observation that we often transferred patients in a palliative situation to the emergency room when it was not their place”recalls Dr. Clément Leclaire, the doctor responsible for Pallida.
Avoid hospitalization
Painful transport, endless waiting before treatment, wandering before eventual hospitalization in the ward if necessary… So many difficult situations, and even more so for people at the end of their lives. While a caregiver at AP-HP’s Home Hospitalization (HAD), Dr. Leclaire convinced some colleagues. “We told ourselves that emergency management for these patients is not the responsibility of palliative care structures or emergency services. On the other hand, it seemed more logical to us that such an approach would rely on HAD and benefit from its knowledge and logistical structure. »
As soon as it is started, the idea is implemented. Its principle: to bring to a patient in vital distress (at home or in a nursing home), in a very short time, all the techniques of palliative care to respond to discomfort or instability that usually requires hospitalization. “Patients who enter this system are not previously registered in the palliative sector or the HAD approach”adds Dr. Leclaire.
The team is available at all times
When the doctor (Samu, on-call doctor, Ephad practitioner) alerts them to the situation, the Pallidom team immediately begins the evaluation phase. “Our phone line for carers is available 24 hours a day, 7 days a week, and we aim to answer three questions: Are we in a palliative situation? Has the patient or his relatives expressed a desire to stay at home? Are we sure there is no benefit to hospitalizing the person? » The discussion lasts an average of 45 minutes. Three yeses: the team can immediately proceed to the intervention phase. The doctor/nurse pair then goes to see the patient without delay, regardless of the time. “We come with a big backpack full of equipment to be able to carry out any type of care,” comments Hélène Mauri, nurse within the Pallidom team.
Although the pathologies that patients suffer from are different, they are divided into three categories that gather approximately the same number of people: terminal cancers, advanced neurodegenerative diseases and organ failure. For those involved, the question is therefore to be able to alleviate breathing difficulties, as well as excruciating pain, anxiety, repeated misdirection, etc. “In our interventions, we provide palliative – that is, comfort – and curative treatmentsspecifies Dr. Leclaire. For example, if a person is short of breath, we give morphine symptomatically and also provide antibiotics and oxygen for treatment. Therefore, there is no loss of opportunity, even if everything takes place at home. »
At the end of this initial intervention comes the follow-up phase, during which the nurse visits the patient between 7 am and 9 pm to reassess him and adjust treatments. “We go to some houses several times a day, to others every 48 hoursnotes Hélène Mauri. In all cases, we call our relatives every morning in order to take stock and decide on a trip if necessary. For their part, they can contact us at any time of the day or night to inform us of developments – which sometimes lead to intervention -, ask us for advice or simply talk and find comfort. » As we can easily guess, the role of caregiver is important in this organization. Caregivers even believe that their involvement in the care project is essential. “The family is more present at the patient’s bedside than we are, admits Hélène Mauri. She may be asked to administer treatments, notify us in case of deterioration, etc. In fact, she is part of the health care team. »
Get to the mark
This monitoring phase generally lasts three to five days, the time for the acute symptoms that warranted the call to Pallidum to pass – or not. “In 19% of cases, patients improve, reports Dr. Leclaire. Then they leave the home hospitalization system. For 8% of them, the situation requires transfer to a palliative care unit. 1% is transferred to the emergency room. Finally, 72% of patients die at home, surrounded by their loved ones. »
Today, 8 doctors, 8 nurses and 2 auxiliary nurses are needed to operate this wonderful machine in the four departments of Ile-de-France where it operates (75, 92, 93 and 94). Enough to receive ten patients a day. A drop in the ocean compared to the 800 patients monitored daily by AP-HP home hospitalization – of which 300 are in palliative care – but an invaluable resource for all those who, despite a very difficult situation, can stay at home in their last moments.