Taking Ownership Module
Pallitaive care
Iniiating Palltive care earlier in the illness: T or F
1. Increases depression
F
2. INcreass anziety
F
3. Reduces hope
F
4. Shortens life expectancy F
Palliative – compassion, dignity, quality of life
Not something for last bit of life
Trajectory – illness to death
When getting palliative care late:
-lack of symptom control
-inappropriate treatment choice
-prolonged psychologic distress
-lack of discussion
-lack of preparation of care plans or choice
Start Palliating early in disease
-more patient center and responsive to patient needed
Temel Study: Compared Late palliative care vs Early palliative care
Results:
Early- less depression, better quality of life, better symptom control, lived longer (3 months)
Defining Palliative care
 “an approach that improves the quality of life of patients and their families facing the
problems associated with life threating illness…”…-WHO, 2002
 “….. is aimed at relieving suffering and improving the quality of life for persons who are
living with or dying from, advanced illness or are bereaved”..- Canadian Hospice
Palliative Care
 “when cure is not possible” –European Society of Medical Oncology
 “care provided for people of all ages who have a life limiting illness” –palliative care
Australia; American society of clinical oncology
Definition of “palliative care” by WHO excludes euthanasia and assisted suicide
Pallative care:
 should be initiated early in the illness trajectory
 is about improving/maintiang best quality of life under the circumstances

can be initiated alongside treatments to control the disease
-initiate early in illness, major culture change
What is the “Palliative Care Approach”
 coined in Australia to differentiate primary-level (or generalist-level) palliative care from
specialist-level palliative care (provided by palliative care specialists)
 should be widely available to all patients/families
 should be provided by all health care personnel
Involves 4 elements
Identify
 identify patients early who may benefit from palliative care or a palliative care approach
Assess
 patients/family understanding of the illness and information needs
 symptoms
 psychosocial & spiritual needs
 quality of lie
 values, wishes, preferences
 other need
 initiate important conversation
Plan
 advance care planning
 goals of care discussions
 care plans
 treatment plans
 link to resources and other care providers
Manage
 symptoms
 psychosocial and spiritual needs
 essential discussion –answer how long
 refer for assistance as needed
 at the end of the day palliative care is essentially good medicine and good care
 ask for help from palliative care specialist team when you need help
 we are all in this together
How to identify when? wo would benefit? When do we need specialist help?
Surprise Question: Would I be surprised fi the patient died in the next 6-12 months? (screening
question)
-purpose is to:
 get people thinking about palliative care approach earlier in the illness
 change culture/raise awareness around early palliative
not:
 used as a prognosis instrument
 accurately determine life expectancy
 suggest that a palliative care approach is limited to patients within the last 6-12 months
Cancer Trajectory much more predictable
PPS Palliative Performance Scale
 assess functional status across 5 domains
 applicable to cancer or non-cancer diagnosis
The Palliative Care approach applies no matter what stage a patient is at in the illness
-idenitfy
-assess
-plan
-manage
Again Surprise Question:
If the answer is no:
 initiate a palliative care approach
-review situation, goals of care
-identify, assess, manage symptoms and other needs
-initiate ACP discussion (if not already done)
Supplement surprise question with clinical criteria that help with prognostication
Gold Standard Framework
-UK-based initiate to improve palliative care in primary care/other settings
-adopted the surprise question
-uses the question in conjunction in general disease specific indicators of decline
other approaches:
Predicting 1-year mortality rate after admission to hospital
“Palliative”: Overcoming the stigma
 should change to another term
 others think that changing the name is not addressing the real issue
What’s in the Name
Nathan Cherny (palliative care specialist, researcher, oncologist)
1. Getting over it
-stick to the term but educate patients and public
2. “Living with it”
-add another term (eg supportive and palliative care)
3. Getting around it”
-replace with another term (eg pain & symptom management)
Each has advantages and disadvantages
1. Getting over it
-ensures education occurs
-may take longer
2. Living with it
-pragmatic
-people may not be educated
3. Getting Around it
-quick and easy
-fails to educate
-important conversations may be avoided
Phrases to Avoid
“is the patient palliative”
“the patient is not palliative yet”
“there is nothing else we can do; you are now palliative”
“Do you want active or palliative care”
Phrases to Use
‘Would this patient benefit from a palliative care approach”
Would this patient benefit from being seen by a palliative care team”?
“This patient is requiring end-of-life palliative care
“Although cure (control of disease) is not possible, we still provide active care”
Who is responsible for palliative care?
Do you have patients who would benefit from a palliative care approach?
Do you have patients who would benefit from being seen by a specialist palliative care team?
Do you provide patients with palliative approach to care?


If you have patients in your practice with disease that are life-limiting, then you DO have
patients that would benefit from a palliative care approach
Palliative care is applicable across all ages and diagnoses
Key point: inappropriate for palliative care to be given only by specialist
Quiz:
1. Palliative care should be activated when it is apparent the patient is entering the last
day or weeks of life ? Tor F -False
2. When we say a patient would “benefit from a palliative care approach”, this meas they
should be refereed to specialist palliative care team T or F – False
3. The trajectory for chronic illness such as advanced heart diseases follows a more
predictabale course than the trajectory for most cancers T or F- Flase chronic illness
follow a more unpredictable coure than most types of cancers
4. Which of the following pharases are appropriate to use when talking about palliative
care or the palliative care approach?
Would this patient benefit from palliative care approach?
-Although cure of the disease is not possible, we can still provide active care
5. The surprise question is a prognosis instrument that can accurately determine life
expectancy? Tor F –false
6. The WHO defines “palliative care” as care directed towards patients with a terminal
disease t or F – false


Key Messages:
palliative care Is not limited to only the last days or weeks of life, and should be initiated
earlier in any patient with life threating illness
Palliative care is the responsibility of all; not limited to only palliative care specialist
teams