A palliative approach can support quality of life for older people at the end-of-life. 'The Surprise Question' can help identify those needing a palliative approach and the 3 key processes help deliver the palliative approach.
Ask yourself:
'Would I be surprised if this person died in the next 6 to 12 months?'
If you would not be surprised if the person died, a palliative approach should be considered.
The
SPICT Tool (494kb pdf) also supports recognition of those is used to identify those with deteriorating health who can be assessed for unmet palliative and supportive care needs.
Three Key Care Processes
The first of the three care processes looks at Advance Care Planning (or ACP). ACP helps guide decision-making when the person can no longer communicate their wishes. ACP discussions should be encouraged for all older people.
The National framework for advance care planning documents describes ACP as:
'...a process of planning for future health and personal care whereby the person’s values, beliefs and preferences are made known so these can guide decision-making at a future time when that person cannot make or communicate his or her decisions'.
Key aspects of ACP:
- Identifying the patient’s wishes and preferences for future care.
- Conducting discussions when a patient or resident is still relatively well.
- Reviewing the ACP regularly to identify if preferences have changed or if there are other things that need to be considered.
- Documenting care decisions that have been discussed.
More information can be found in
Advance Care Planning section.
When it is likely that death could occur in the coming months, a palliative care case conference should be organised. A palliative care case conference can help review and clarify goals of care and treatment plans as the older person’s anticipated death gets nearer.
Key aspects of palliative care case conferences:
- Indicates and creates acceptance that the person may be in the last months of life.
- Alert clinicians to review the older person’s condition, their care needs and future care plan.
- Incorporates broader assessment which integrates comorbidities, physical, emotional, psychological and social factors.
- Provides discussion about choices to be made in the event of a sudden decline or deterioration.
- Facilitates the ability to act on preferred choices through discussions with the older person and/or their substitute decision maker.
- Addresses common clinical symptoms: pain, shortness of breath, nutrition and hydration issues, delirium and oral care.
- Provides a shared care plan to be reviewed regularly.
More information can be found in the
Palliative Care Case Conference section.
In the last days of life a planned approach to care is important.
Terminal care planning should lead to a structured multidisciplinary care plan which details the essential steps for the care of the dying person. It should address any specific clinical problems the person has or is likely to encounter. This will help ensure care that is focused on the individual’s needs
Key aspects of terminal care planning:
- Goals of care focus on the older person’s physical, emotional and spiritual comfort as well as support for the older person’s family even If there is uncertainty when the death will occur.
- Regular review of care goals and plans
- Discussion with the family
- Recognition of the signs and symptoms which suggest terminal care planning is needed. Three or more of the following signs suggest that terminal care planning needs to be considered:
Remember the decision to start terminal care is a team decision that takes into account all the relevant clinical information. Discussions with the person and their family about the change in care focus are critical.
More information can be found in the
Terminal Care Planning section.