Excellent Practices
Palliative Care through the Patient Pathway
Practice Category: Treatment
Centre: Vall d’Hebron Barcelona Hospital Campus
Claudia Valverde
CCC Coordinator
cvalverde@vhio.net, claudia.maria@allhebron.cat
Challenge addressed by the practice
One of the principal challenges currently faced is the provision of care across multiple healthcare settings, driven by the growing population of oncology patients. Care is, delivered in different contexts, including HVH inpatient units, Pere Virgili inpatient care, outpatient clinics, and through coordination with home-based care services.
Another important challenge involves caring for patients from diverse nationalities and cultural backgrounds. This requires intercultural sensitivity, adapted communication strategies, and an understanding of differing values, beliefs, and expectations related to illness and care.
Additionally, continuous social changes have increased the diversity of family structures, personal circumstances, and socioeconomic contexts. As a result, healthcare professionals face highly heterogeneous situations that demand flexible and responsive care models, avoiding standardised approaches and promoting person-centred care within each patient’s social environment.
Solution
To address the need for care across different healthcare settings, a transversal and coordinated care model has been implemented to ensure continuity throughout the disease trajectory. Clear communication pathways have been established among HVH and Pere Virgili inpatient units, outpatient services, and home care teams, supported by procedures and protocols designed to prevent fragmentation of care.
To meet the needs of patients from diverse cultural and national backgrounds, intercultural care strategies have been introduced, including cultural mediation and coordination with spiritual care support. These measures facilitate effective communication and ensure respect for patients’ values, beliefs, and expectations.
In response to ongoing social changes and increasing family and socioeconomic diversity, a flexible, person-centred approach has been adopted. Comprehensive assessments covering clinical, social, emotional, and family dimensions enable the development of individualised care plans tailored to complex and evolving needs.
Impact
A Multidisciplinary Team Involvement discuss the patient’s situation, ensuring that each team member contributes with his or her expertise to create a holistic understanding of the patient’s needs.
The goal is to develop an individualised care plan based on the assessment findings.
There is patient and family engagement in the treatment planning process, with family meetings when needed.
The goal would be:
- Earlier referral to palliative care
- Reduced use of futile interventions
- Improved anticipatory care planning
Critical success factors
- Symptom manage assessment and daily addressed
- Management approach to refractory symptoms at the end of life
- Adequacy of comfort well monitored and documented
- Management approach to dying patients who are unable to be managed at home; they are admitted with priority for single rooms to ensure their privacy and intimacy during this difficult time
Key factors:
- Staff training
- Integration of screening tools into the medical record
- Periodic review of results
Next steps
The center needs to have a continuity of education programmes that include:
- Expanding early integration of palliative services throughout the cancer trajectory
- Enhancing interdisciplinary collaboration
- Strengthening communication with patients and families
Future developments may focus on personalised symptom-management plans, improved psychological and spiritual support, and wider use of telehealth to ensure continuity of care.
Ongoing evaluation will prioritise patient-reported outcomes, quality-of-life measures, and caregiver support. Future research needs to be done.
