Palliative care is provided to people like William; people who, regardless of age, have a life-limiting illness. It is not dependent on a specific medical diagnosis, but on a person’s needs.[1-4] Palliative care is also applicable when caring for frail older people and people with chronic and non-malignant conditions.[5-8]
The course of various life-limiting illnesses can be influenced by a range of factors. Some of these factors include:
|The natural history of the illness:
For example, people with cancer can often remain well and function reasonably for prolonged periods, but experience a sudden decline before death.
|Presence and nature of comorbidities:
For example, curative treatment for a co-morbid condition would be warranted for a person with a slowly progressive cancer causing limited functional decline.
|Treatment goals and decisions:
For example, treatment goals for someone with slow functional decline will aim to maximise function and quality of life. Treatment goals also focus on reducing symptoms for example, for someone with end-stage heart failure who has pulmonary oedema.
The top five causes of death in Australia are chronic in nature. In general, these illnesses follow three broad and relatively predictable trajectories:
Trajectory images source: Murray, S.A., et al., Illness trajectories and palliative care. BMJ: British Medical Journal, 2005. 330(7498): p. 1007-1011.
Key points about illness trajectories:
- Each phase of an illness trajectory can bring its own particular meanings and challenges for people affected by life-limiting illness. [3, 12]
- Knowledge of the likely course of an illness helps predict the progression of the person’s condition. For example, curative treatment for a co-morbid condition can be warranted for a person with a slowly progressive cancer causing limited functional decline[3, 12-14]
- Physical, social, psychological, and spiritual needs are likely to vary according to the trajectory being followed. [15, 16]
- Understanding the likely course of an illness can help guide clinical assessment and choice of treatment options. If the treatment helps the person function and fits in with their treatment goals, then such treatment can be appropriate.
- Understanding what symptoms are likely to be part of the person’s illness trajectory can assist with proactive symptom assessment and management. Determining the effect of these symptoms on the person, and how they perceive these symptoms, is highly important.[3, 12-17]
- The end-phase of life can become apparent when particular changes in the status of a person’s functions or symptom profile occurs. This phase can initiate changes in supportive interventions for the person and their family. The Supportive and Palliative Care Indicators Tool (SPICT)TM can be used to help identify people whose health is deteriorating and who may require further assessment of unmet holistic care needs.
- The ‘Surprise Question’ – “Would you be surprised if this person were to die within the next 6-12 months?” has been incorporated into clinical guidelines and routine clinical practice in many settings as a way to help clinicians identify people who would benefit from palliative care. 
- Identify the key points distinguishing the following definitions:
- Palliative care
- End-of-life care.
- How do you determine who requires palliative care? Consider:
- Issues associated with a person’s health needs
- The personal resources and strengths they can draw from.
- Review the illness trajectories and the three associated case studies, answer the following questions:
- How are these trajectories similar or different to that of a person who is dying as a result of the ageing process?
- How can people’s anticipation of death and preparations for end-of-life be influenced by an understanding of illness trajectories?
- How would you answer the ‘Surprise Question’ for the patients described in each of these case studies?
- World Health Organization. Definition of Palliative Care. 2017 [cited 2017 March 13]; Available from: http://www.who.int/cancer/palliative/definition/en/.
- Palliative Care Australia. Palliative Care Service Development Guidelines. 2018; Available from: http://palliativecare.org.au/quality.
- Murray, S.A., et al., Palliative care from diagnosis to death. BMJ, 2017. 356.
- Thoonsen, B., et al., Early identification of palliative care patients in general practice: development of RADboud indicators for PAlliative Care Needs (RADPAC). Br J Gen Pract, 2012. 62(602): p. e625-31.
- Palliative Care Australia, Guidelines for a Palliative Approach in Residential Aged Care: self directed learning package – manual. 2013.
- End-of-life essentials: education for acute hospitals. Introducing specialist palliative care services. 2016 March 2018]; Available from: https://www.caresearch.com.au/caresearch/Portals/0/EoLEssentials/MJA-8-Introducing-specialist-palliative-care-services.pdf.
- Elliott, M. and C. Nicholson, A qualitative study exploring use of the surprise question in the care of older people: perceptions of general practitioners and challenges for practice. BMJ Supportive & Palliative Care, 2017. 7(1): p. 32-38.
- Vickerstaff, V., et al., 60 Can the ‘surprise question‘ be used to correctly identify people nearing the end of life?: a review. BMJ Supportive & Palliative Care, 2017. 7(3): p. A371-A371.
- Murray, S.A., et al., Illness trajectories and palliative care. BMJ : British Medical Journal, 2005. 330(7498): p. 1007-1011.
- Australian Institute of Health and Welfare, Australia’s health 2016. 2016, AIHW: Canberra.
- Kendall, M., et al., Different Experiences and Goals in Different Advanced Diseases: Comparing Serial Interviews With Patients With Cancer, Organ Failure, or Frailty and Their Family and Professional Carers. Journal of Pain and Symptom Management, 2015. 50(2): p. 216-224.
- Murray, S.A., et al., Illness trajectories and palliative care. BMJ, 2005. 330: p. 1007.
- Amblàs-Novellas, J., et al., Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories. BMJ Open, 2016. 6(9): p. e012340.
- Skornick-Bouchbinder, M., J. Cohen-Mansfield, and S. Brill, Trajectories of End of Life: A Systematic Review. The Journals of Gerontology: Series B, 2017. 73(4): p. 564-572.
- Beernaert, K., et al., Palliative care needs at different phases in the illness trajectory: a survey study in patients with cancer. European Journal of Cancer Care, 2016. 25: p. 534-543.
- Gardiner, C., et al., Exploring the transition from curative care to palliative care: a systematic review of the literature. BMJ Supportive & Palliative Care, 2015. 5(4): p. 335.
- Lloyd, A., et al., Physical, social, psychological and existential trajectories of loss and adaptation towards the end of life for older people living with frailty: a serial interview study. BMC Geriatrics, 2016. 16(1): p. 176.
- White, N., et al., How accurate is the ‘Surprise Question at identifying patients at the end of life? A systematic review and meta-analysis. BMC Medicine 2017. 15(139).