Abstract
This reflection details how the purchase of a small portable ultrasound system enabled a pilot domiciliary paracentesis service. The service offers symptom relief through ascitic drainage to palliative, end-of-life, patients who wish to avoid a hospital admission.
Identifying appropriate patients and considering risk, the service is offered and supported by appropriately trained advanced practitioners along with palliative, oncology and district nursing teams.
A small number of patients have been involved, but anecdotally, this has offered great relief and comfort to both the patients and their families.
The ongoing aim is continue offering this service and make more community teams within our area and beyond aware of its existence and to support the training of interested and skilled palliative health care professionals in performing these.
Introduction
Advances in ultrasound technology, specifically the development of small, portable handheld devices which can provide detailed high-quality imaging, has enabled practitioners to rethink traditional approaches to imaging and the settings in which interventional procedures can be undertaken. In addition, the COVID pandemic fostered an approach of supporting vulnerable patients in avoiding a hospital attendance if possible.
Working in a rural District General Hospital, with a moderate sized population but spread over a large geographical area with a limited transport system, and no local end-of-life Hospice bed provision led to a discussion regarding the possibility of a paracentesis service outside of the traditional hospital setting.
During the pandemic the oncology treatment department moved out of the District General Hospital (DGH) and into the now unused hospice building to enable immunocompromised and vulnerable patients to avoid the need to attend the general hospital setting during their treatment regimen. The purchase of an in-house ultrasound machine by the hospice enabled a sonographer to visit and assess patients when there was a concern of ascitic cumulation and when appropriate to support or perform day-case paracentesis procedures for those patients who would benefit from it. With doctors and nurses on site, patients could be supported, monitored, and discharged home at the end of the day.
The ultrasound department of the same DGH then, funded by the League of Friends, was able to acquire a GE Vscan Air and iPad. This device raised the question: with a collaborative approach, could the ultrasound, palliative and community teams perform a paracentesis service within the patient’s home. It was decided to pilot this service.
The risk of off-site procedures had already been assessed for the hospice site–based procedures and, as the numbers of patients involved were expected to be low, it was decided that a cost analysis was not required.
Abdominal ascites and paracentesis
The accumulation of large volumes of abdominal ascites due to liver cirrhosis or a cancer can cause patients to feel breathless, fatigued, and nauseous, affecting appetite and bowel movements. 1
Sometimes ascites build up can be managed by diet or medication, or treatments such as chemotherapy can prevent, or reduce the presence of ascites by treating the underlying cause.
When ascites cannot be effectively managed by a non-invasive treatment it can lead to a significant volume accumulating, often many litres. A therapeutic, also known as a large volume, paracentesis, may be considered, removing the abdominal ascites over the course of a few hours via a drainage catheter introduced into the peritoneal cavity. The patient is usually required to either be admitted to hospital or attend as a day case, spending a whole day within the hospital whist the drain is in situ, but the procedure can improve the patient’s general comfort and associated symptoms.
The role of ultrasound in performing a safe paracentesis is well acknowledged, Cho et al 2 list some of the benefits as reducing the risk of bleeding or organ damage, identifying abdominal wall thickness and identifying if there is insufficient volume to drain. Ultrasound can be used to mark a safe site of access, or the procedure can be performed under direct ultrasound visualisation.
In the absence of a large volume of ascites performing a procedure is unlikely to improve how the patient is feeling and the risks of performing a procedure would outweigh the benefits. Ultrasound assessment can determine when it would be appropriate to proceed to a drainage procedure.
An Ultrasound scan also enables the identification of other causes of abdomen distension such as a bowel obstruction or disease progression, thus ensuring an unnecessary procedure is avoided.
When a patient is requiring frequent large volume paracentesis a tunnelled drain also known as indwelling or long-term drain can be considered and may be preferable to a repeated large volume paracentesis. This allows the ascites to be drained by the patient and/or the community nursing team within the patient’s home setting, avoiding frequent and recurrent trips to hospital, and reducing the accumulation of large, uncomfortable volumes of fluid. Kaur et al 3 retrospectively reviewed long term drains versus repeat large volume paracentesis procedures and concluded long term drains were safe, effective and may reduce hospital admissions and the use of healthcare resources. However, the patient cohort for the domiciliary service are within the last few short weeks of life and a permanent drain would not be necessary or appropriate.
Within our DGH setting two experienced sonographers both perform the paracentesis procedures as well as train and support other medical professionals and advanced non-medical staff practitioners.
We have found the advanced practitioner role to be vital in offering continuity of service and in meeting training provision requirements in our rural setting where it can be challenging to recruit and retain appropriately trained and experienced staff.
The two aforementioned sonographers have the experience of performing both the ultrasound assessment and of the interventional procedure to know when a drain is, or is not appropriate and, with appropriate measures in place, to be able to safely perform the procedure, even in a non-hospital setting.
Suitable patients for a domiciliary paracentesis
The term palliative can be applied to anyone who has a life limiting condition and may be in the last year of their life. However, these patients may still be otherwise quite well, mobile and safe to attend a hospital setting for treatments, investigations, monitoring and procedures. 4
However, as a condition or disease progresses, inevitably a patient will become less well, and ultimately house bound when nearing the end of their life. Attending a hospital for treatment can be difficult both logistically, organising ambulance transport and inpatient bed availability, as well as emotionally when the patient and their families wish them to be at home.
Performing interventional procedures within a domestic setting will have greater potential risk than within the hospital environment, and therefore, it is of utmost importance to identify when a patient is suitable to have this done.
Levels of contraindication and risk may be adjusted when a patient is reaching the last few short days or weeks of their lives and having open and informed conversations between healthcare professionals and the patient and their family prior to consideration of treating the patient in their home is vital to ensure understanding and agreement, and to manage expectations of outcomes.
With Hospital at Home, and community efforts trying to reduce patient admissions we have found it necessary to be specific and steadfast in our criteria for identifying a suitable patient as a care giver who routinely works in people’s homes will likely have a different threshold than the ultrasound team. A domiciliary paracentesis is a resource heavy procedure to organise and convenience for the patient is not an appropriate reason.
We have identified appropriate people for this service as
Likely within the last 6 weeks of their life
Bed bound
Uncomfortably distended by ascites, affecting their appetite and causing nausea
Have a support network to be with the patient while draining, that is, family, to empty the drainage bag
It can be difficult to determine the cause of abdominal distension from a physical examination alone. Experience in performing a physical examination can be helpful but even then, we have found patients to be distended due to bowel obstruction, or disease progression, or there may be insufficient fluid to offer a therapeutic benefit from a drainage. This reinforces the importance of having an experienced operator performing and interpreting the Ultrasound scan, and in performing the paracentesis procedure to know when suitable to proceed or not as well as being confident and competent in managing complications that may arise.
A collaborative approach
As previously acknowledged a domiciliary paracentesis is a resource heavy procedure, often taking significant time out of the sonographer’s day and involving multiple teams’ input.
When the potential patient’s home is near to the DGH it can be worthwhile to visit and perform an ultrasound examination to assess suitability for the treatment prior to organising all the teams involved. However, covering such a large rural area a patient can live a good distance from the hospital, perhaps 1–2 hours away, and in those cases it is likely worthwhile assuming the procedure will go ahead and plan to proceed if possible, in one visit.
When the hospice and oncology staff identify a patient that they feel would benefit from a drainage and fits the required criteria they will contact the sonography team to discuss.
Once it has been agreed to plan to proceed the district nursing team are contacted. The district nurses play a vital role in supporting this service. They will attend and assist the sonographer at the time of the procedure, provide a link for the family during the day and remove the catheter once the drainage is completed.
We have found the district nursing teams to be enthusiastic in supporting this service. Assisting with the drain insertion offers an understanding of the procedure and confidence in removing the drain at the end of the day.
Once the drain is in situ the sonographer will usually remain at the home for a while to show the family how to empty and dispose of the ascitic fluid from the drainage bag and ensuring there are no immediate post-procedure complications.
End-of-life patients with cirrhosis are discussed with the gastroenterology team for consideration of this procedure without human albumin serum infusion, the use of which can be indicated to reduce the risks of circulatory dysfunction complications or hyponatraemia. If the patient is within a few short days of the end of their life and the procedure is able to offer a therapeutic improvement in their discomfort it may be appropriate to continue.
Cases to date
If the criteria are strictly followed there are few suitable patients so despite this being a costly procedure in terms of time and staff resources, we have only had 13 patients referred in the past 26 months, so it is deemed a valuable service both ethically and in removing the cost of transfer and an unwanted hospital admission.
No patient has required a repeat domiciliary procedure. One patient survived 60 days post procedure, the five remaining patients died between 9- and 29 days post procedure, an average of 27.5 days, suggesting we have identified and selected the correct patients.
The families of the patients have reported their gratitude of the relief and improvement of discomfort that this procedure has brought to their loved one in the last few short days of their lives.
Spreading the word
A literature search found few articles documenting the success of performing paracentesis in the home/hospice setting overseas,5–7 but there was no literature identified highlighting the possibility or benefits of performing this type of procedure in the domestic setting within the United Kingdom.
Other service providers within the Southwest region are becoming aware of this service and liaising with us over requirements and considerations for implementing it within their Trust area.
We have trained one of our palliative doctors to perform these procedures and they are now about to commence their FAMUS training to gain confidence and knowledge in performing the Ultrasound assessment. The local palliative teams are keen to support this service and, in the future, with appropriate experience, may ultimately reduce the need for the sonographers involvement. It is expected we will remain the point of contact as subject matter experts regarding the ultrasound imaging, supporting with equivocal or complex findings and image interpretation.
Conclusion
Advances in portable imaging is offering opportunities to revisit traditional working practices and consider developing practices that previously have not been possible.
Despite a domiciliary paracentesis being a resource heavy procedure, with the few numbers involved it is considered ethically valuable and cost-effective in offering comfort for both the patient and families within their own home at the end of their life and avoiding a costly unwanted transfer into hospital.
Clear inclusion and patient suitability criteria should be defined and shared with all teams involved.
Appropriately trained advanced practitioners can provide this service with the support of the palliative and oncology staff and the district nursing teams.
Footnotes
Contributors
SS primary service lead. HM primary author.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics approval
N/A.
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No.
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No.
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Guarantor
SS.
