Case studies

The need to discuss with the patient issues associated with awareness and ‘diagnosis’ of a palliative state such as worsening symptoms, failure of treatments due to progressive disease or recurrent disease.

A discussion is held with the patient and palliative care team regarding timely assessment of symptom management, ability to manage illness, changing goals, wishes, and future needs. Discussions regarding EOL wishes, plans and goals are shared throughout the health care team and may be discussed at MDC meetings as planning processes. The discussions are then continued with the patients by members of the palliative care team who are known by the patient. The outcomes of conversations are shared with the entire MDC team to continue the communication process. Documentation of this plan is mandatory.

Regular assessment and awareness of individual patient’s disease and progression will lead to early and appropriate referral to the palliative care team. This will facilitate smooth transition into the palliative phase, thus allowing planning and respect of patient goals and wishes to be established.

A conversation is held with the patient at an appropriate time (individually determined by a senior clinician), to discuss ‘not for resuscitation’ (NFR) orders.

The initial discussion occurs at a time when the patient is not unwell or under stress (e.g. it is not appropriate when diagnosis is first given to them). It is explained to the patient that a discussion about NFR orders is best done before admission occurs. An explanation of the meaning of NFR and the processes involved with resuscitation is given. The issues relating to medical advice, appropriateness of treatment, the patient’s right to choice and medical futility can be undertaken as needed. Written information will be provided to all. Admitting doctors should check the patient’s ‘NFR status’ at each admission and ask the patient if they would like to change their status. It is suggested that their status is included in a card also recording their medications.

The patient and their caregivers have the opportunity to be properly informed about this difficult and emotive topic. As a result, stress is reduced both for the patient and the family, as well as the doctors involved. This also avoids the distressing situation where a doctor unfamiliar with a patient, and their medical history, prognosis and other details, is required to determine the NFR status of a patient, often in the situation of the patient being acutely unwell.

Initiating a referral to palliative care.

Effective communication within the health care team to help determine appropriate and timely referral to the palliative care team is crucial. The referral is introduced to the patient and their carers by the designated care coordinator explaining the role of palliative care as one of active care that delivers specialised health care to maximise quality of life, whether that be symptom management, pain relief or spiritual, emotional, and psychological support.

Introducing the discussion about palliative care is assessed within the MDC team on an individual basis dependent upon the patient’s advancing illness and their hopes for the future.

An advanced breast care nurse routinely assesses a patients newly diagnosed with advanced breast cancer.

An advanced breast care nurse explains to the patient the role of key team members as providers of support, information, and symptom control. Once the patient is comfortable and aware of the value of this care, the advanced breast cancer nurse may suggest, if appropriate, that a similar support role can be provided in the community, also by a specialist nurse (from the community palliative care provider).

Patients begin to separate the supportive care role of palliative care services, distinguishing them from terminal care. Patients become more accepting of supportive care provision in the community from palliative care services.

Involving general practitioners in MDC.

To ensure that GPs participated in the planning phase, with a view to their participation in MDC meetings, focus groups were held at clinics in the regional area and through the Division of General Practice in two rural health services. Attendance at these meetings was impressive and though the attendees identified many obstacles to attendance at MDC meetings, they were enthusiastic about participating.

GPs routinely attend the MDC meeting in the regional centre and on many occasions in the rural centres. The relevant Division of General Practice is notified of the name of the GPs who are to have patients discussed that week and through this mechanism, GPs are invited to the meeting. The liaison GP from the Division of General Practice attends the majority of meetings and is able to convey information about treatment planning to those GPs unable to attend the meeting.

The patient’s GP initiating a MDC meeting in a rural/regional setting.

To ensure the patient’s GP is involved in the MDC planning, cancer care coordinators were introduced to a rural/regional health service to provide the link between GPs and other specialists in the care team. The patient’s GP works closely with the patient’s care team and can initiate a care planning meeting by contacting the lead clinician. The GP is encouraged to attend the meetings in person or participate via teleconference.

Information presented by the GP about the patient’s history and psychosocial issues at the MDC planning meeting has influenced decision-making around treatment and care planning.