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Guide: A Framework of Palliative Care for Community-Based Aged Care

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  • Introduction
  • The framework of palliative care
  • Benefits of the framework
  • Decision Assist palliative care educational opportunities and resources
  • Educational activities with RACGP and ACRRM
  • Other resources
  • Introduction

    In Australia the demographics of death are changing. Today most people die an expected death from one or a combination of various chronic progressive conditions. The majority of Australians report that they would prefer to be cared for and die at home, but in reality only a minority achieve this outcome. As most deaths are expected, death can be planned for and required care delivered in a pre-emptive fashion. General practitioners (GPs) have a central role in planning and providing for that care.

    The framework of palliative care

    The framework of care, as illustrated below, is a tool for GPs to manage older patients with advanced chronic conditions (malignant and non-malignant) more proactively. It can be routinely implemented in general practice, e.g. as part of over-75 health assessment, or during regular visits by this patient cohort.
    The trigger question asked to commence the framework, “Would you be surprised if your patient were to die in the next 6-12 months?”, can be answered using clinical knowledge, personal knowledge of the patient, discussions with the patient, clinical intuition, a combination of all or some of those, or by using a prognostication tool.

    Trajectory 1 (prognosis of greater than 6-12 months)

    • Answer to the surprise question: ‘Yes’
    • Key clinical process: Advanced care planning
    • Advance care planning is an interactive ongoing process of communication between a competent person and/or their substitute decision maker, family/carers and health care providers focussing on the person’s preference for their care in the future.

    Trajectory 2 (prognosis of less than six months)

    • Answer to the surprise question: ‘No’
    • Key clinical process: Case conference
    • The aim of palliative care case conferencing is to identify clear goals of management so that stakeholders are “all on the same page”.

    Trajectory 3 (prognosis very limited, usually less than a week)

    • Answer to surprise question: ‘No’
    • Key clinical process: Terminal care management plan
    • Terminal care management plans will vary depending on whether the patient is being cared for in a residential aged care facility or at home. Care of patients in this trajectory is focussed on regular assessment and attention to patient comfort and family distress and comfort.

    Benefits of the framework

    It is important to recognise that the framework is not about getting the patient prognosis exactly right, but to increase mindfulness of proactively managing clinical needs that typically emerge in the last year of life. Routine implementation of the framework of care can help to ensure that patients receive the right care, at the right time, and in the right place. A likely outcome will be increased satisfaction with GP care.

    Decision Assist palliative care educational opportunities and resources

    Further information: www.decisionassist.org.au

    Educational activities accredited with RACGP and ACRRM

    Workshop
    An opportunity for GPs to learn to apply a framework of care, based on prognostic trajectories, to identify the palliative care needs of aged patients. Experience indicates that the framework facilitates GPs to deliver the right care, in the right place at the right time.
    Refer to listing on www.decisionassist.org.au
    RACGP: 4 Category 2 QI&CPD points
    Activity No: 10883
    ACRRM: 2 PRPD points
    Activity No: E1406ANSP

    Clinical audit for GPs
    An opportunity for GPs to review their approach to managing the care of older Australians with advanced chronic conditions living in the community
    Contact: karencooper.ANZSPM@bigpond.com
    RACGP: 40 Category 1 QI&CPD points
    Activity No: 12239
    ACRRM: 30 PRPD points
    Activity No: E1401BSPC

    Other Resources

    Videos
    An opportunity for GPs to increase their ability to manage common symptoms in palliative care:

    1. An introduction to the management of dyspnoea in the palliative care environment
    2. Pain: assessment, management and initiating opioid treatment
    3. An introduction to the management of delirium in the palliative care environment
    4. An introduction to the management of nausea and vomiting in the palliative care environment

    Phone Advisory Service
    1300 668 908

    • Palliative care advice provided by specialist palliative care staff 24/7
    • Advance care planning advice 8:00am-8:00pm (jurisdictionally specific)

    Mobile phone app: palliAGED
    An opportunity for GPs to access prescribing and management advice to care for dying patients, and simple tools to identify older age patients who would benefit from a palliative care approach to care.
    Download at the following stores: