UBC Objectives: Care of the Elderly & Priority Topic: Palliative Care

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and manage common end of life care issues (e.g. nutrition, dysphagia, code status, hospital transfer, home and LTC visits)

Key Feature 1: In all patients with terminal illnesses (ex: end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e., do not limit the use of palliative care to cancer patients). 
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment

Key Feature 2: In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e., use a team approach when necessary). 
Skill: Patient Centered
Phase: Treatment

Key Feature 5: In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (ex: wishes for treatment of infections, intubation, dying at home)
Skill: Patient Centered, Clinical Reasoning
Phase: History, Hypothesis generation

Today I began my palliative care rotation at St Paul's Hospital. I met 4 different patients on the ward all receiving palliative care for very different reasons. All patients had incurable but not unmanageable disease states, including end-stage chronic obstructive pulmonary disease, impaired postoperative wound healing in the setting of severe frailty, advanced congestive heart failure, and metastatic esophageal cancer. Although only one of these patients had a diagnosis of cancer, all of them had symptoms that warranted management according to the principles of palliative care. For a succinct overview of what palliative care entails, see the WHO Palliative Care webpage.

Central to the palliative care approach is the appreciation of an individual's total suffering, which includes sources of physical pain  but also areas of emotional, social, and spiritual pain, among other domains. The benefit of a multidisciplinary team strategy when taking a comprehensive perspective of pain cannot be understated; while the physician is certainly an expert in treating physical sources of pain with analgesia, this is but one method of alleviating pain associated with life-limiting and life-threatening illness. The book, "Palliative medicine: A case-based manual" by Oneschuk, Hagen, and MacDonald (2012) provides examples of the ways in which various health care professionals may contribute to alleviating a patient's total suffering:

• A spiritual care provider can provide counselling and support for patients and their families
• A social worker can address the family’s stress, as well as coordinating hospital discharge planning
• A psychologist can provide psychological assessment and treatments
• Physiotherapists and occupational therapists can contribute to pain management interventions (ex: acupuncture, splinting, energy conservation strategies)
• Dieticians can assist with symptoms, including anorexia–cachexia
• Professionals skilled in complementary therapies—including relaxation, meditation, massage, and distraction—can address stress and anxiety
• Trained volunteers can provide valuable support to patients and their families through companionship and activities

There are many methods of mitigating suffering, many of which may or may not be useful or desirable to a specific individual given the context of their circumstances and how it interacts with their beliefs, values, and wishes. As a treating physician, it is important to have conversations that explore these considerations, as indicated by the context. Whenever any medical decision is made, it is always important to ensure the decision is being made with informed consent. Furthermore, it may be important given certain circumstances to begin thinking about the decisions one may want for their health in anticipation of a future time when they may no longer be able to speak for themselves. This is particularly important when a patient is at greater risk of an incapacitating illness or event (although some say it is never too early to start having these conversations because you just never know). Regardless, it is always important to have these conversations with patients diagnosed with a terminal illness, and the sooner the better, when more time can be given to proper reflection. When done well in advance, this is typically the process of Advance Care Planning (ACP), and consists of reflecting on one's values and wishes for future health care decisions, along with identifying a person whom they would want to make decisions for them if/when they cannot make decisions for themselves (aka a substitute decision maker [SDM]), and communicating this verbally or as documented in writing (far preferable). This may include conversations about Goals of Care, which are more focused health care goals given a situation at hand (ex: What a patient's goals are for a given hospital admission and the scope of what they would and would not want to receive in terms of medical management. This would include but is not limited to clarification of the patient's Code Status.) The conversation does not end here of course, and each medical decision should be done with informed consent as given by the patient or the SDM if indicated. And as patients' circumstances and occasionally their beliefs, values, and wishes change, it is important to revisit ACP accordingly. If there has has been no ACP, then urgent decisions will need to be made regardless for medical decisions at hand, but research indicates that the outcomes are far more ideal for patients and care providers if these conversations are begun well in advance. The Pallium Palliative Pocketbook lists benefits of ACP as follows:

• End-of-life wishes are known and followed
• Less stress and anxiety for family members
• More satisfaction with care
• Better quality of life and quality of death
• Less use of inappropriate health resources

For more information on ACP, check out www.advancecareplanning.ca.