CareSearch Blog: Palliative Perspectives

'Staying at home' is a bit of a mantra for palliative care. When time is precious, home and family beckon as a place of safety and comfort, where a person can completely be themselves. Yet for so many reasons it is not always easy to achieve – and particularly the goal of a home death.  In this blog post I will reflect on my recent experience in community palliative care in Northern Sydney, and how general practitioners and palliative care services together can help make this happen for patients, and to happen well.

First of all, why is this hard?  I can list a few factors that mitigate against patients being cared for well and comprehensively at home. Firstly, complexity of treatment plans and multiplicity of treating teams means that many patients are 'working full-time' as patients. Decision-making responsibility and prognostic leadership are diffused between multiple teams: the oncologists (medical and radiation), surgeons, palliative care, and doctors managing other chronic conditions. These may be spread across multiple public and private sites of care, with variable access to information about what is planned and why.

Providing palliative care in rural settings brings unique rewards and challenges. While many aspects of the care that rural practitioners provide are similar to that of our urban colleagues, the nature of practice in small towns and rural settings dictates some significant differences. The likelihood of knowing our patients outside the professional sphere is greater, and we not infrequently find ourselves caring for friends, their families, and colleagues. Absence of direct access to specialist palliative care services mean that much of our patients’ end-of-life care is provided by generalists – GPs, hospital doctors, domiciliary nurses, rural and remote and hospital nursing staff. Geography and distance may require innovative solutions, reliance on telephone consultations, and sometimes admission to hospital earlier than would be the case in urban centres.

The care that people receive as they approach the end of their life really does matter. It matters to the person, it matters to the people who love them, and it is a reflection of our societal values. Everyone is affected by death during their lives and everyone dies; indeed, death is a universal health outcome. We need to do end-of-life care well.

Decision Assist, funded by the Australian Government Department of Health, recognises that GPs and aged care workers should be supported to provide quality end-of-life care to meet the needs of older Australians.  

To help support GPs, ANZSPM, as a part of Decision Assist, is promoting a framework of care that is based on a palliative approach and suitable for people in the last year of life and can help guide clinicians to provide high quality end-of-life care focussing on a person’s preferences for care and proactive delivery of holistic comprehensive care. 

In its 'Dying Well' report published in September last year, the Grattan Institute said 14% of Australians die in their own home. The option of care at home is often well-received by patients and carers alike. Enablers for people to remain at home include support from their general practitioner (GP) as well as access to good symptom control.

Given the small proportion of people who require support at home in the last days of life and the infrequency of managing this patient group, there are some simple tips for GPs to consider with regards to prescribing medicines. These five tips help the GP to anticipate the barriers to timely access to good symptom control and possibly avoid an unnecessary hospitalisation for an issue that could have been effectively managed in the community.