All times

Integrating palliative and supportive with disease modifying care

With cancer, traditionally there was a period when a cure was attempted, then when cure was no longer possible, palliative care intervened. The new and better concept is that supportive and palliative care should start at diagnosis of a life-threatening illness and gradually increase while disease modifying care may decrease.

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Research has shown that patients can manage both preparation for death and hope for the future, as they tend to have dual, competing narratives in their mind.(1)

The 'surprise' question

In the organ failure and frailty trajectories it has previously been more difficult to conceptualise and decide when a palliative care approach might be clinically appropriate. However, examining a typical organ failure trajectory, it is evident that events or triggers such as a hospital admission might be utilised to consider changing a chronic disease management approach, dealing largely with physical concerns, to a supportive and palliative care approach.

Alternatively, there might be clinical indicators such as breathlessness at rest, or even the "surprise question". This question is where a physician asks himself or herself the question "would I be surprised if this patient were to die in the next year"? If the answer is "no" consideration should be given to any additional supportive care needs of both the patient and carer(s) at this time.

Are there any tools to help identify individuals who may benefit?

A number of tools have been developed for use in primary care to help GPs and community nurses identify patients as they transition to a point when a supportive and palliative care approach is beneficial. The Supportive and Palliative Care Indicator Tool (SPICT) can be used opportunistically at patient consultations, or by scanning patient disease registers to identify such patients for a comprehensive assessment and a palliative care approach.(2) A copy of the SPICT tool can be found under 'resources'.

What about the last days of life?

In the last days of life, starting the patient on an end-of-life care pathway can ensure individualised care and that consideration is given to stopping unnecessary treatments and tests.