PC15 Palliative care Rationale and general practice context 1. Palliative care requires a multidisciplinary approach, with the general practitioner playing a central and increasing role, especially in the management of domiciliary care. For example, in 2002, of the approximate 134,000 deaths that occurred in Australia, about 64,000 (almost 50%) of patients would have been cared for by a GP several times during their last 12 months of life. 4 2. Most patients who die an easily predictable death from a diagnosed terminal illness want to be cared for at home (>50%). However, only about 16% are able to exercise this option, as most patients now die in hospital; only 20% of people die in hospices and 10% in nursing homes. 5 3. The community sector is increasingly caring for people at home rather than in hospital, and GPs often coordinate sometimes fragmented and competing community services and advocate on behalf of patients, their families and carers for community based palliative care. 6,7 4. Like other doctors, GPs are largely trained to work with curative or life prolonging models of health and many GPs have identified that they require further education in the skills that underpin the practice of palliative care, such as basic communication skills, symptom control and management skills, and skills for dealing with death and dying. 8 5. The provision of good general practice and community based palliative care requires GPs to organise their practices appropriately to help build and configure best use of community based health networks (eg. specialist hospital based to community based teams) to meet the palliative care needs of their patients, and their families and carers, for quality, comprehensive healthcare at the end-of-life in the setting of their choice. 9 6. Like any other area of medicine, GPs need to utilise evidence based clinical decisions when providing general practice palliative care and access current palliative evidence bases such as CareSearch 10 and Therapeutic guidelines palliative care. 11 7. There are government initiatives in palliative care, and GPs need to work in conjunction with government health priorities and other organisations toward better palliative care services. Related curriculum areas Oncology Pain management. References 1. Department of Health and Ageing. Palliative care. 2014. Available at www.health.gov.au/palliativecare. 2. Mitchell GK. Whither general practice palliative care? Aust Fam Physician 2006;35:757. 3. Word Health Organization. World Health Organization definition of palliative care. Geneva: World Health Organization. 2014. Available at www.who.int/cancer/palliative/definition/en. 4. Palliative Care Australia. A guide to palliative care service development: a population based approach. Canberra: Palliative Care Australia; 2005. 5. CareSearch. Palliative care knowledge network. 2014. Available at www.caresearch.com.au/caresearch/default.aspx. 6. Therapeutic Guidelines. Palliative care. Version 3. Melbourne; 2010. Available at www.tg.org.au/?sectionid=47. 7. Australia and New Zealand Society of Palliative Medicine. Palliative care curriculum for undergraduates (PCC4U). 2014. Available at. http://www.pcc4u.org
8. Australian Health Ministers Advisory Council. From hospital to home improving care outcomes for older people. A national action plan 2004 2008. 9. Australian Institute of Health and Welfare. Older Australia at a glance. 4th edn. Canberra: Australian Institute of Health and Welfare; 2007. 10. Cairns W, Yates PM. Education and training in palliative care. Med J Aust 2003;17(Suppl):S26 8. 11. Storey L Pemberton C Howard A, et al. Place of death: patient choice or Hobson s choice? Cancer Nursing Practice 2003;2:4 10. 12. CareSearch. Palliative care knowledge network. 2014. Available at www.caresearch.com.au/caresearch/default.aspx. 13. Therapeutic Guidelines. Palliative care. Version 3. Melbourne; 2010. Available at www.tg.org.au/?sectionid=47.[this is the current version] 14. The Royal College of General Practitioners. Care of people with cancer and palliative care. 2011. Available at http://webcache.googleusercontent.com/search?q=cache:iitj-myuh8sj:www.rcgp.org.uk/trainingexams/gp-curriculum-overview/~/media/files/gp-training-andexams/curriculum%2520previous%2520versions%2520as%2520at%2520july%25202012/rcgp- Curriculum-12-Cancer-and-Palliative-Care-2011.ashx+&cd=2&hl=en&ct=clnk&gl=au 15. Australia and New Zealand Society of Palliative Medicine. Palliative care curriculum for undergraduates (PCC4U). 2010. Available at.http://www.pcc4u.org/learning-modules/core-modules/1-principles/ 16. Kristjanson L, Lobb E, Aoun S, Monterosso L. A systematic review of the literature on complicate grief. Churchlands: Western Australian Centre for Cancer and Palliative Care, Edith Cowan University; 2006. 17. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine? National Institutes of Health; 2014. Available at http://nccam.nih.gov/health/whatiscam. 18. Natural Medicines Database. Available at www.naturaldatabase.com. 19. The Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities. 4th edn. Melbourne: The RACGP; 2006 http://www.racgp.org.au/download/documents/guidelines/silverbook.pdf
Learning outcomes and criteria Domain 1 Communication and the doctor-patient relationship Learning outcomes lifelong learning PC1.1 Establish and foster effective and empowering and therapeutic relationships with patients, carers and families. PC1.1.1a Describe the issues specific to working with patients, carers and families. PC1.1.2a Describe the difference between caring and curing. PC1.1.3a Identify diversity between patients within families and cultures. PC1.1.4a Describe specific communication skills to enable the best care for patients and their families/carers at the end-oflife. PC1.1.5a Illustrate how spiritual, religious and cultural issues affect patient perception of illness and death, and treatment decisions. PC1.1.1b Develop rapport with patients, their carers and families. PC1.1.2b Prioritise care based on quality of life. PC1.1.3b Identify and manage differing perceptions and expectations of disease and treatment between patients and among various family members. PC1.1.4b Communicate bad news and poor prognosis competently and empathically. PC1.1.5b Define the realistic context of illness at the end-oflife for the patient and their family. PC1.1.6b Communicate and address end-of-life issues with patients and their carers. PC1.1.1c Manage end-of-life issues for patients and their families/carers. PC1.1.2c Review and revise procedures that address end of life care. PC1.1.7bManage psychological, social, cultural and spiritual aspects of the patient s illness. PC1.2 Assist patients and their carers to maintain their quality of life. PC1.2.1a Describe ways of managing patient expectations PC1.2.2a identify interventions for people with life-limiting illnesses and their families PC1.2.3a Describe the experience and consequences of terminal illness from the perspective of the patient and their family. PC1.2.1b Describe ways in which meaningful physical and mental activity can be supported and maintained. PC1.2.2b Implement appropriate support services to assist preservation of patient s quality of life PC1.2.1c Co-ordinate patient care to ensure that all members of the team are cognisant of the patient s views PC1.2.4a Analyse the impact of caregiving on family and carers. 3
Learning outcomes lifelong learning PC1.3 Identify, evaluate and manage grief and bereavement. PC1.3.1a Describe grief processes for families/carers. PC1.3.2a Describe how personal and cultural beliefs can impact on the provision of care. PC1.3.1b Prepare carers for bereavement PC1.3.2b Provide support during the bereavement process. PC1.3.3b Manage bereavement issues for families/carers. PC1.3.1c Evaluate and build on skills in assisting patients, carers and family manage their grief and bereavement. PC1.3.4b Coordinate services when ongoing care and support is required. PC1.4 Facilitate communication with relevant healthcare professionals. PC1.4.1a Identify essential components of effective referrals. PC1.4.2a Explain multidisciplinary interprofessional communication. PC1.4.1b Identify appropriate healthcare professionals that can support patients, carers and families. PC1.4.2b Establish high quality referral systems to enable comprehensive care of all aspects of required care. PC1.4.1c Establish and nurture networks of health professionals to enable comprehensive care of complex palliative patients 4
Domain 2 Applied professional knowledge and skills Learning outcomes lifelong learning PC2.1 Identify a broad range of illnesses requiring palliative care PC2.1.1a List a variety of malignant and non-malignant illnesses that may require palliative care. PC2.1.1b Recognise common symptoms seen in palliative care. PC2.1.2b Use symptom checklists and screening tools as diagnostic support tools. PC2.1.1c Review and apply new and emerging evidence in palliative care to ensure best practice standards are met. PC2.1.3b Organise a prioritised management checklist. PC2.1.4b Implement diagnostic and treatment algorithms. PC2.2 Determine Indicators of disease progression. PC2.2.1a Describe the pathology of the symptoms of terminal illness. PC2.2.2a Describe prognosis and quality of life issues. PC2.2.1b Undertake an effective assessment of a palliative patient to establish a comprehensive management plan. PC2.2.2b Organise appropriate investigations in a palliative patient. PC2.2.1c Promote quality care and optimise palliative care health outcomes. PC2.2.3b Differentiate disease pathways in malignant and nonmalignant terminal illnesses and the impact this has on patients and their families. 5
Learning outcomes lifelong learning PC2.3 Evaluate and manage end-of-life symptoms PC2.3.1a Describe types of pain and other symptoms. PC2.3.2a Describe potential end-of-life emergencies. PC2.3.2a Explain the management principles for common symptoms and health problems associated with life-limiting illnesses. PC2.3.1b Organise appropriate investigations in palliative emergencies. PC2.3.2b Identify treatments for specific diseases and symptom control. PC2.3.3b Utilise a range of palliative care interventions. PC2.3.4b Effectively manage identified symptoms. PC2.3.1c Reflect on the identified symptomatology and ensure that treatment reflects the patient s priorities. PC2.3.2c Commit to ongoing professional development that promotes the best available evidence based practice. PC2.3.3c Use this knowledge to provide patients with the best management. PC2.3.5b Anticipate, diagnose and manage potential problems. PC2.3.6b Identify and implement therapy in palliative emergencies. PC2.4 Accurately prescribe medications commonly used in palliative care. PC2.4.1a Describe the drugs commonly used in palliative care and their indications, doses and routes of administration. PC2.4.2a Describe dose equivalence of opioids PC2.4.1b Describe the prescribing implications of renal and hepatic impairment. PC2.4.2b Manage possible interactions between prescribed drugs and any complementary and alternative medicines. PC2.4.1c Refer to available databases to advise patients on the available evidence of efficacy, safety and adverse interactions PC2.4.3a Outline signs of opioid toxicity. PC2.4.3b Use appropriate subcutaneous infusion devices in palliative care. PC2.4.4b Effectively apply the PBS palliative care section. 6
Domain 3 Population health and the context of general practice Learning outcomes lifelong learning PC3.1 Co-ordinate relevant community services PC3.1.1a Describe the role of the GP in the palliative care setting. PC3.1.2a Describe the role of GPs operating within a multidisciplinary team PC3.1.1b Assess and interpret each patient s links to family and friends. PC3.1.2b Advocate for equity of access to multidisciplinary palliative care services. PC3.1.3b Demonstrate establishment of relationships and networks with other community services. PC3.1.1c Describe the demographics of terminal illness, especially in relation to non-malignant conditions. PC3.1.2c Forge and maintain relationships with community palliative care service providers. PC3.1.4b Advocate for access for those from disadvantaged groups and their families/carers. PC3.2 Effectively utilise available healthcare resources. PC3.2.1a Describe palliative care budgetary and human resource limitations. PC3.2.1b Negotiate prudent usage of palliative resources. PC3.2.2b Prioritise investigations and management. PC3.2.1c Describe and implement, where appropriate, policies and standards for palliative care. PC3.3 Manage palliative care for Aboriginal and Torres Strait Islander people. PC3.3.1a Describe palliative care issues specific to Aboriginal and Torres Strait Islander people. PC3.3.1b List palliative care resources specific to Aboriginal and Torres Strait Islander people. PC3.3.1c Maintain currency of evidence based best practice in Aboriginal and Torres Strait Islander people palliative care. PC3.3.2b Incorporate Aboriginal and Torres Strait Islander people beliefs, rituals and traditions into their care. PC3.3.3b Manage Aboriginal and Torres Strait Islander patients through terminal care. PC3.3.4b Advocate for Aboriginal and Torres Strait Islander people. 7
4 Professional and ethical role Learning outcomes lifelong learning PC4.1 Maintain professional standards of behaviour when managing palliative patients. PC4.1.1a Discuss the unique emotional and spiritual issues that arise for a palliative patient. PC4.1.1b Manage patient wishes to decline treatment. PC4.1.2b Advocate strongly for patient needs, including accessing best practice resources. PC4.1.1c Apply current and best practice palliative care knowledge to all patients. PC4.2.1c Negotiate advanced health directives and end-of-life planning as appropriate. PC4.1.3b Manage ethical issues and conflicts in patient care. PC4.1.4b Identify and manage personal beliefs that impact on interactions with patients and their care. 8
5 Organisational and legal dimensions Learning outcomes lifelong learning PC5.1 Coordinate multidisciplinary teamwork. PC5.1.1a Outline role of team care and care planning for palliative patients. PC5.1.2a Identify sources of support for people with lifelimiting illnesses and their families/carers. PC5.1.3a Describe relevant models of healthcare and service delivery. PC5.1.2b Apply appropriate Medicare items relevant to palliative care. PC5.1.2b Identify and use local medical, nursing, allied health, community and respite services. PC5.1.3b Facilitate access to relevant appliances and aids to daily living for palliative patients. PC5.1.4b Negotiate the implementation of appropriate services for palliative patients. PC5.1.5b Coordinate the ongoing provision of services. PC5.1.6b Outline barriers to the provision of coordinated services. PC5.1.1c Identify gaps in knowledge, skills and attitudes in relation to evidence based palliative care. PC5.1.2c Monitor the effectiveness of the team to assist in developing strategies to address identified gaps in knowledge, skills and attitudes. PC5.1.3c Structure the clinic/practice to accommodate palliative patients. PC5.1.4c Undertake regular audits of management practices in dealing with palliative care patients and their families/carers. PC5.2 Apply relevant legislative and administrative requirements. PC5.2.1a Describe state legal issues associated with end of life care PC5.2.1b Describe identification and certification of death, and surrounding legal issues. 9
Requirements for competence Pregeneral practice lifelong learning Required knowledge Role of palliative care within the health care system Disease trajectories for malignant and non-malignant terminal illness Common symptoms in end of life care Grief process Dynamics within families of terminally ill patients Range of clinical resources Comprehensive knowledge of available pharmacologic interventions The Australian healthcare system Health promotion theory and practice Referral methods and sources Universal precautions Duty of care theory and practice Availability of a range of resources related to supporting patients and their families Interpreting demographic data Access and equity in the context of the patient and the setting Community resources Relevant guidelines Required skills Good communicatio n skills Delivering bad news History taking- bio-psycho-social Performing physical examinations Negotiation and problem-solving Communication skills (verbal and non-verbal) appropriately applied in a range of contexts Managing emergence of long repressed memories Advocacy Developing management plans with patients, their family/carers and other providers. Essential procedural skills Diagnostic skills Managing complications and emergencies Clinical decision-making Prescribing appropriately and cost effectively Research and evaluation Holistic care Setting and up working with practice systems such as appointments, recall etc. Required attitudes Empathy Inquisitiveness Empathy Patience Resilience Professionalism Self-directedness Rapport and empathy Dealing with uncertainty and ambiguity Collegiality Self-awareness Consistency Evidence required to demonstrate competence Case studies Supervisor reports Symptom lists Record of palliative care attachments or electives Log book Case histories Records of visits to palliative care facilities Lists of support services and how to access them etc CDP records of workshop and course attendance. Methods of assessment Small group projects Literature review Reflective essays Report writing Clinical notes including referral letter review Observations Simulations Role-play Third party reports 360 feedback Clinical audit 10
Random case analysis Written and verbal questioning Range statement 1 Communication and the doctor/patient relationship Interventions Can include those that will optimise physical, psychological and social function for people with life-limiting illnesses and their families End-of-life issues can include giving bad news, developing realistic expectations and maintaining hope, managing grief processes for families/carers which progress beyond the patient s death during their bereavement phase dealing with unfinished business Multidisciplinary Encompasses the shared care of the patient between a number of different health, allied health and community professionals and organisations. 2Applied professional knowledge and skills Appropriate investigations Need to take into consideration the context of the patient s illness and quality of life concerns. Terminal illnesses Can include cancer, neurological degenerative disease (eg. motor neurone disease, end stage dementia), organ failure (eg. chronic obstructive pulmonary disease, congestive cardiac failure), frailty and dementia, and HIV/AIDS Symptom control Can include palliative surgery, radiotherapy and chemotherapy, nutrition and hydration, mouth care, pressure area care. Symptoms can include pain (nociceptive, visceral, neuropathic and complex); nausea and vomiting; constipation; anorexia; hiccoughs; fatigue, weakness and lethargy; delirium and confusion; dyspnoea; depression and anxiety; existential distress; malignant effusions; peripheral lymphoedema. 3 Population health and the context of general practice Community services Can include nursing, allied health, domiciliary services, pastoral care. Coordination of community services can include care of the patient, health beyond that of the individual patient, advocacy regarding community needs, needs of disadvantaged groups, cross-cultural partnerships. 4 Professional and ethical role Professional standards of behaviour Can include negotiating and agreeing on treatment modalities, priorities and goals of treatment in partnership with patient/family/carers; resource allocation to best serve the health needs of the population on the basis of need and equity of access to care and support; recognition of personal emotional stress and seeking assistance appropriately; understanding of patient and community perspectives on a good death ; the need to complete unfinished business; the issues surrounding relief of suffering and euthanasia. 5 Organisational and legal dimensions Barriers to the provision of coordinated services 11
These can include intra-practice issues, time management and financial constraints. Legislative and administrative requirements can include death certificates, advanced health directives, medical power of attorney, enduring guardianship requirements, carer s allowance applications, will preparation, testamentary capacity Structure Can include accommodating home visits for palliative patients, when appropriate, arranging adequate clinical handover to partners or preferred after hours providers to ensure continuity of care at all hours for palliative care patients and their families. 12