Hospital-to-home transition of individuals receiving palliative care in light of Afaf Ibrahim Meleis’ theory

Authors

  • Angélica de Cássia Bitencourt Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: angelicacbitencourt@gmail.com. https://orcid.org/0000-0002-3516-9688
  • Denise Maria de Paula Santa Casa de Alfenas, Alfenas, Minas Gerais, Brasil. E-mail: mgdenisepaula@gmail.com. https://orcid.org/0009-0009-3523-5030
  • Luciana Helena Pereira Fagundes Hospital Gimirin de Poço Fundo, Poço Fundo, Minas Gerais, Brasil. E-mail: lucianaoncologia@gmail.com. https://orcid.org/0009-0004-9752-8967
  • Anicheriene Gomes de Oliveira Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: annyoli12@hotmail.com. https://orcid.org/0000-0001-9361-6768
  • José Vitor da Silva Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: enfjvitorsilva2019@gmail.com. https://orcid.org/0000-0001-9045-1398
  • Zélia Marilda Rodrigues Resck Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: zelia.resk@unifal-mg.edu.br. https://orcid.org/0000-0002-3752-8381
  • Silvana Maria Coelho Leite Fava Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: silvana.fava@unifal-mg.edu.br. https://orcid.org/0000-0003-3186-9596
  • Eliza Maria Rezende Dázio Universidade Federal de Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brasil. E-mail: eliza.dazio@unifal-mg.edu.br. https://orcid.org/0000-0001-9216-6283

DOI:

https://doi.org/10.5216/ree.v27.77687

Keywords:

Palliative Care, Patient Discharge, Transitional Care, Nursing Theory, Nursing

Abstract

Objective: to reflect on the hospital-to-home transition process of individuals receiving palliative care, based on Afaf Ibrahim Meleis’ Transitions Theory. Methods: theoretical-reflective study based on publications (non-systematic search) on the subject in Portuguese, Spanish, and English from 2018 to 2023, retrieved from the databases Embase, LILACS, MEDLINE (via PubMed of the National Library of Medicine), and Web of Science, using the controlled descriptors: Transitional care, Patient discharge, and Palliative care. Results: the reflections are presented across three thematic axes: facilitating conditions in the hospital-to-home transition process for individuals in palliative care; inhibiting conditions in the hospital-to-home transition process for individuals in palliative care; and therapeutic nursing interventions. Conclusion: it is essential that healthcare professionals observe, assess, and plan the transition process, taking into account all facilitating and inhibiting conditions, in order to ensure the continuity of safe care for individuals in palliative care and their families.

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References

Radbruch L, Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining palliative care - a new consensus-based definition. J Pain Symptom Manage. 2020 May 6;60(4):754–64. https://doi.org/10.1016/j.jpainsymman.2020.04.027

Ministério da Saúde (BR), Secretaria-Executiva, Superintendência Estadual do Ministério da Saúde no Rio de Janeiro. Desospitalização: reflexões para o cuidado em saúde e atuação multiprofissional [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2023 May 15]. 170 p. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/desospitalizacao_reflexoes_cuidado_atuacao_multiprofissional.pdf

Weetman K, Dale J, Mitchell SJ, Ferguson C, Finucane AM, Buckle P, et al. Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study. BMC Palliative Care. 2022 Sept 6;21:155. https://doi.org/10.1186/s12904-022-01038-8

Coleman EA, Boult C. improving the quality of transitional care for persons with complex care Needs. J Am Geriatr Soc. 2003 Mar 26;51(4):556-7. https://doi.org/10.1046/j.1532-5415.2003.51186.x

Souza FN, Silva VG, Silva AS. Factors associated with emergency room visits or hospitalization in care oncology home care: an integrative review. R Pesq Cuid Fundam. 2023;15:e12000. https://doi.org/10.9789/2175-5361.rpcfo.v15.12000

Cordeiro FR, Kruse MHL. It possible to die at home? Analysis of the Brazilian and French scenarios. Texto contexto - enferm. 2019 Apr 8;28:e20170602. https://doi.org/10.1590/1980-265X-TCE-2017-0602

Freire MOL, Gomes WL, Braga JEF, Macêdo JQ. Compreensão de pacientes sobre a continuidade do pós-operatório, a partir do autocuidado domiciliar. Ciencia y Enfermeria. 2021;27:4. https://doi.org/10.29393/ce27-4cpml40004

Santos TL, Laprano MGG, Conceição AP. Orientações de alta hospitalar para o desempenho do autocuidado após a cirurgia cardíaca: revisão integrativa. Rev baiana enferm. 2020 July 27;34:e35284. https://doi.org/10.18471/rbe.v34.35284

Silva FRR, Pereira RA, Souza AC, Gimenes FRE, Simino GPR, Dessote CAM, et al. Construction and validation of a booklet for home palliative care after hospital discharge. Acta Paul Enferm. 2022;35:eAPE028112. https://doi.org/10.37689/acta-ape/2022AO02812

Meleis AI. Transitions Theory: Middle range and situation- specific theories in research and nursing practice. New York: Springer Publishing Company; 2010.

Mertens F, Sercu M, Derycke A, Naert L, Deliens L, Deveugele M, et al. Patients’ experiences of transfers between care settings in palliative care: an interview study. Ann Palliat Med. 2022 Sept 27;11(9):2830-43. https://doi.org/10.21037/apm-22-146

Marston C, Morgan DD, Philip J, Agar MR. Experience and acceptability of a carer-focussed intervention in acute oncology settings: A qualitative study of people with advanced cancer and their carers. Aust Occup Ther J. 2023 June 4;70(5):570–80. https://doi.org/10.1111/1440-1630.12887

Isenberg SR, Killackey T, Saunders S, Scott M, Ernecoff NC, Bush SH, et al. “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 Feb 22;62(3):e9-19. https://doi.org/10.1016/j.jpainsymman.2021.02.026

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 June 13;29:3382-91. https://doi.org/10.1111/jocn.15371

Arias-Rojas M, Carreño-Moreno S, Posada-López C. Incerteza dos cuidadores familiares na doença de pacientes sob cuidados paliativos e fatores associados. Rev Lat Am Enfermagem. 2019 Oct 14;27:e3200. https://doi.org/10.1590/1518-8345.3185.3200

Van Der Plas AGM, Oosterveld-Vlug MG, Pasman HR, Schweitzer B, Onwuteaka-Philipsen BD. Continuity of GP care after the last hospitalization for patients who died from cancer, chronic obstructive pulmonary disease or heart failure: a retrospective cohort study using administrative data. Fam Pract. 2018 June 30;36(3):304-9. https://doi.org/10.1093/fampra/cmy065

Olario PS, Moreira MC, Moreira IB, Martins JCA, Souza AT. Desospitalização em cuidado paliativos: perfil dos usuários de uma unidade no Rio de Janeiro/ Brasil. Cogitare Enferm. 2018 July 5;23(2):e53787. https://doi.org/10.5380/ce.v23i2.53787

Acosta AM, Câmara CE, Weber LAF, Fontenele RM. Atividades do enfermeiro na transição do cuidado: realidades e desafios. Rev enferm UFPE on line. 2018 Dec 2;12(12):3190-7. https://doi.org/10.5205/1981-8963-v12i12a231432p3190-3197-2018

Saunders S, Weiss ME, Meaney C, Killackey T, Varenbut J, Lovrics E, et al. Examining the course of transitions from hospital to home-based palliative care: A mixed methods study. Palliat Med. 2021 Sept 2;35(8):1590-601. https://doi.org/10.1177/02692163211023682

Scott M, Shaver N, Lapenskie J, Isenberg SR, Saunders S, Hsu AT, et al. Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review. Palliat Med. 2020 Oct 4;34(1):5-15. https://doi.org/10.1177/0269216319870649

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 Aug 8;34(10):1316-31. https://doi.org/10.1177/0269216320947601

Villalon GE. Continuidad del cuidado. Evidencia Actualizacion En La práctica Ambulatoria. 2021;21(1):e002112. https://doi.org/10.51987/evidencia.v24i1.6922

Almeida Filho RF, Trezza MCSF, Comassetto I, Silva LKB, Lopes MP, Santana KGS, et al. Espiritualidade na incerteza da doença: a perspectiva de pacientes oncológicos. Rev Bras Enferm. 2023 Oct 9;76(4):e20220712. https://doi.org/10.1590/0034-7167-2022-0712pt

Santos AFJ, Ferreira EAL, Guirro UBP. Atlas dos Cuidados Paliativos no Brasil 2019 [Internet]. São Paulo: Academia Nacional de Cuidados Paliativos (ANCP); 2020 [cited 2025 June 03]. 52 p. Available from: https://paliativo.org.br/wp-content/uploads/2020/05/ATLAS_2019_final_compressed.pdf

Portaria nº 825 do Ministério da Saúde, de 25 de abril de 2016 (BR). Redefine a Atenção Domiciliar no âmbito do Sistema Único de Saúde (SUS) e atualiza as equipes habilitadas [Internet]. Brasília: Ministério da Saúde; 2016 [cited 2023 June 06]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2016/prt0825_25_04_2016.html

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Published

2025-07-25 — Updated on 2025-08-15

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Issue

Vol. 27 (2025)

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Reflection Article

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