As people progress along their illness trajectory they can require input from specialist palliative care services. Specialist palliative care services work directly with people affected by life-limiting illness and in partnership with other care providers to coordinate and deliver care.
Triggers for referral to specialist palliative care include:[2-6]
- It would not be a surprise if the person died within the next 12 months or during this admission [7, 8]
- Recurrent presentations to hospital
- Progressive illness despite life prolonging therapy
- Low probability of success from available therapeutic options
- Withdrawal, or consideration of withdrawal, of prolonging treatment (e.g. hemodialysis, ventilation)
- Concern about end-of-life issues
- Recent marked decline in physical function
- Care needs exceed health professional scope and carer capacity.
Specialist palliative care teams provide advice, support and interventions to manage complex and persistent needs including:[3, 9]
- Psychological concerns
- Social and or spiritual distress
- Ethical dilemmas
- Family issues.
Guidelines presented in the PREPARED framework provide useful principles to facilitate communication about palliative care. Additional recommendations to prepare people during this transitional time include:[9-15]
- Providing a private environment, with adequate time for a full discussion
- Delivering information openly and honestly about changes in illness, treatment efficacy and, where requested, prognosis
- Eliciting the person’s concerns and goals before discussing specific clinical decisions
- Providing reassurance, where possible, when concerns have been discussed
- Introducing palliative care workers early
- Incorporating all health professionals involved in the person’s care as a team
- Exploring the person’s understanding of palliative care
- Emphasising the role of palliative care throughout the illness
- Explicitly stating that optimal care will continue and that the person will not be abandoned
- Asking open questions, including:
- “What concerns you most about your illness?”
- “What has been most difficult about this illness for you?”
- “What are your hopes and expectations and fears about the future?”
- “As you consider the future, what is most important to you?”
- “Is faith (religion, spirituality) important to you in this illness?”
- “Would you like to explore religious matters with someone?”
(adapted from Table1. Clinical practice guidelines for the psychosocial care of adults with cancer.)
Consider these points in relation to Michelle.
Michelle attends a follow-up appointment with Dr Meredith North, her medical oncologist. She has completed her radiotherapy and has commenced palliative chemotherapy. She is exhausted and looks unwell.
She is symptomatic with breathlessness and expresses her concern about this. Meredith assesses her breathlessness and develops a management plan with Michelle and Pete. As part of this plan, she introduces the concept of palliative care.
- What are the main sources of distress for Michelle and Pete at this time?
- What specific communication strategies did Meredith use to:
- Respond to Michelle’s distress?
- Introduce the concept of palliative care?
- What additional communication strategies could the oncologist use to improve this interaction?
- Access the CareSearch factsheet “Introducing specialist palliative care services”.
- Review the examples of useful phrases and consider how you can use them in your role.
- Are there other phrases you have found helpful when communicating about palliative care?
- Palliative Care Australia. National Palliative Care Standards. 2018; 5th Edition:[Available from: http://palliativecare.org.au/standards].
- WA Cancer and Palliative Care Network. Referral to Specialist Palliative Care. 2014 March 2018; Available from: http://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Palliative/12810_referral_to_palliative_care.ashx.
- 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.
- 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.
- Marcucci, F.C.I., et al., Identification and characteristics of patients with palliative care needs in Brazilian primary care. BMC Palliative Care, 2016. 15(1).
- Palliative Care Australia. Identifying Palliative Care Needs. 2017 [cited 2018 22/6/2018]; Available from: https://www.caresearch.com.au/caresearch/tabid/1507/Default.aspx.
- Thomas, K. Principles and materials for The Gold Standards Framework. 2018 [cited 2018 July 24]; Available from: http://www.goldstandardsframework.org.uk/.
- 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.
- Palliative Care Australia. Palliative Care Service Development Guidelines. 2018; Available from: http://palliativecare.org.au/quality.
- Kaplan, M., SPIKES: a framework for breaking bad news to patients with cancer. Clin J Oncol Nurs, 2010. 14(4): p. 514-6.
- Rosenzweig, M.Q., Breaking bad news: a guide for effective and empathetic communication. The Nurse practitioner, 2012. 37(2): p. 1-4.
- CareSearch. Communication. 2018 [cited 2018 12/07/2018]; Available from: https://www.caresearch.com.au/caresearch/tabid/3392/Default.aspx.
- Monden, K.R., L. Gentry, and T.R. Cox, Delivering bad news to patients. Proceedings (Baylor University. Medical Center), 2016. 29(1): p. 101-102.
- Ferreira da Silveira, F.J., C.C. Botelho, and C.C. Valadão, Breaking bad news: doctors skills in communicating with patients. Sao Paulo Medical Journal, 2017. 135: p. 323-331.
- Seifart, C., et al., Breaking bad news-what patients want and what they get: evaluating the SPIKES protocol in Germany. Annals of oncology : official journal of the European Society for Medical Oncology, 2014. 25(3): p. 707-711.