Core Modules

module 3 | Activity 6: Principles of palliative symptom management

In order to be person-centred, any approach to symptom management must take into account the wishes of the person and the goals they want to achieve.[1]  These goals canrange from the person wishing to maintain and improve functional levels, return to work, go to a family wedding or other social event, or wishing to be cared for at home when required.[2] Throughout their illness goals may need to be adjusted to cater for deterioration or increased symptom burden.

Comprehensive symptom management

The person’s goals of care help to inform the overall management plan.[1, 3-5] Comprehensive symptom management involves:[1, 2, 6-9]

  • A thorough, holistic assessment
  • Identification of appropriate interventions
  • Implementation of the interventions
  • Ongoing evaluation of outcomes of the interventions.

Effective management typically requires:[7, 10-12]

  • An integrated approach that involves holistic, multidimensional symptom assessment and management. For example, pain management can include both opioid analgesia and relaxation strategy education to manage the anxiety related to uncontrolled pain.
  • A targeted approach that is directed at specific causal mechanisms and factors contributing to the concern. For example, different pharmacological agents may be needed to target different mechanisms or types of pain.
  • A tailored approach that is suitable for the person’s unique circumstances, beliefs and preferences. For example, people who do not have carers or adequate financial resources often require additional support from the interdisciplinary healthcare team.

Comprehensive symptom management is achieved through:[1]

Setting a management plan
  • Develop a personalised symptom management plan that includes the person’s goals of care
  • Ensure that all options presented to the person are evidence-based and best practice
  • Outline benefits and burdens of treatments from the person’s perspective
  • Consider illness-modifying treatment for progression of underlying life-limiting illness if it is contributing to symptoms and treatment is appropriate
  • Treat potentially reversible concurrent illness if it is contributing to symptoms and treatment is appropriate, including non-pharmacological and pharmacological therapies
  • Consider the most appropriate and least burdensome route of administration when prescribing drug therapies. When possible, the oral route is preferred however alternate routes may be considered
  • Address social, spiritual, existential, cultural and geographical concerns that may contribute to symptom presentation or management
  • Use anticipatory care planning and prescribing that takes into consideration:
    • Expected worsening of symptoms
    • Development of possible new symptoms
    • Development of symptoms that may occur as a crisis or an acute terminal event
    • The person’s wishes expressed in their advance care plan, if they have one.
Implementing the management plan
  • Clearly document and communicate the proposed care plan and the role of the person, their family and carers
  • Ensure that the care plan is flexible and responsive to the person’s changing needs and priorities throughout their illness
  • Discontinue any treatments / medications that may be causing or exacerbating the symptom(s)
  • Provide the person with written details for whom to contact or how to seek medical assistance if:
    • symptoms worsen or do not improve
    • other concerns occur
  • Provide the person with a copy of the management care plan so that they can more easily communicate their goals and health history with other care providers
  • Use psychological and emotional support to assist the person (and their family and carers) to cope with symptoms
  • Be prepared for change. Many palliative illnesses progress quickly and extreme situations of distress can require rapid changes to management plans.
Monitoring the management plan
  • Adopt a proactive approach – ongoing monitoring, reassessment and re-evaluation of the symptom management plan will be required throughout the person’s illness
  • Plan when the person will be followed up and ensure that they know when, by whom and where they will be reviewed
  • When reviewing the person and their management plan, be thorough and pay attention to details of the presenting symptom(s) and any new concerns or symptoms
  • If a symptom does not improve, review and update the management plan
  • Highlight small improvements
  • Be prepared to adjust management plans to suit responses to treatment, specialised needs or deterioration.

 

Managing specific symptoms 

Clinical evidence summaries informing the assessment and management of specific symptoms occurring in palliative care can be found on the CareSearch website.

  1. In the first video, Herbert states: “I’ve got a lot of living to do.” What does this statement indicate about his goals of care?
  2. Describe what is involved in developing a comprehensive symptom management plan.
  3. How can you ensure that the goals of care are included in the symptom management plan?
  4. Referencing CareSearch, investigate two symptoms of your choice using the following headings:
    • Underlying causes
    • Effects on emotional, social and spiritual wellbeing
    • Evidence supporting pharmacological interventions
    • Evidence supporting non-pharmacological interventions
    • Monitoring the effectiveness of interventions.
  5. How can you ensure that the palliative interventions for these symptoms are:
    • Holistic
    • Integrated
    • Targeted
    • Tailored to the person
  1. Therapeutic Guidelines Ltd, Principles of symptom management in palliative care. 2018: Melbourne.
  2. CareSearch. Symptom Management at the End of Life. Clinical Evidence 2018  [cited 2019 February 02]; Available from: https://www.caresearch.com.au/caresearch/ClinicalPractice/Physical/EndofLifeCare/SymptomManagementattheEndofLife/tabid/741/Default.aspx.
  3. Schellinger, S.E., et al., Patient Self-Defined Goals: Essentials of Person-Centered Care for Serious Illness. The American journal of hospice & palliative care, 2018. 35(1): p. 159-165.
  4. Lum, H.D. and R.L. Sudore, Advance Care Planning and Goals of Care Communication in Older Adults with Cardiovascular Disease and Multi-Morbidity. Clinics in geriatric medicine, 2016. 32(2): p. 247-260.
  5. You, J.J., et al., Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 2014. 186(6): p. 425-432.
  6. International Association for the Study of Pain. IASP Terminology. 2018 2018 [cited 2018 8/10/2018]; The following pain terminology is updated from “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.]. Available from: http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698.
  7. CareSearch. Assessment Tools. Patient Management 2017  March 27, 2017 ]; Available from: https://www.caresearch.com.au/caresearch/tabid/748/Default.aspx.
  8. Network, H.T.P. Symptom Management. 2018  [cited 2018 August 8, 2018]; Available from: http://www.supportivepalliativecare.com/Pages/Symptom-Management.aspx.
  9. CareSearch. Symptom Management. Clinical Evidence 2018  [cited 2019 February 14]; Available from: https://www.caresearch.com.au/caresearch/tabid/1466/Default.aspx.
  10. World Health Organization. Definition of Palliative Care. 2017  [cited 2017 March 13]; Available from: http://www.who.int/cancer/palliative/definition/en/.
  11. World Health Organization, WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings, D.o. HIV/AIDS, Editor. 2005: Geneva.
  12. Aranda, S., A framework for symptom assessment, in Palliative Care Nursing: A Guide to Practice, M. O’Connor and S. Aranda, Editors. 2003, Ausmed Publications: Melbourne.