Coordination of palliative care

Patients with palliative care needs often have complex problems that require a team approach. This team may include:

Any general practitioner (GP) or specialist who cares for patients with a life-limiting illness can provide palliative care. It is important that one person (generally a senior doctor) takes responsibility for the patient’s care to ensure that decisions are made, care is properly coordinated, and healthcare professionals are aware of their responsibilities. A case manager may be required for complex cases.

Note: Any GP or specialist who cares for patients with a life-limiting illness can provide palliative care.

The palliative care of many patients can be managed in the community by general practitioners, and in hospitals by almost any specialty team. Not all patients with a life-limiting illness need referral to a specialist palliative care service; however, referral may be beneficial for patients with complex problems.

Note: All patients with a life-limiting illness can benefit from palliative care, but not all need specialist palliative care services.

Patients often wish to maintain their relationship with the healthcare professionals they already know, such as their GP or specialist physician (eg cardiologist, nephrologist, oncologist). These relationships should be encouraged whenever possible, regardless of who is primarily responsible for a patient’s care. Some patients may feel abandoned or rejected if these relationships do not continue.

Sharing up-to-date clinical information is essential when patients and their carers are dealing with different parts of the healthcare system. This may occur via a healthcare record kept in the home, a shared electronic patient record, or by electronic transfer of information between relevant healthcare professionals. A bedside notebook or other patient-held record can be a useful tool for healthcare professionals, patients and carers.

Note: A bedside notebook (or other patient-held record) can be a useful tool for healthcare professionals, patients and carers.

The following information should be readily available to healthcare professionals involved with the patient:

  • a diagnosis and problem list, including extent of disease and active comorbidities
  • an up-to-date medication list including dosage regimen and purpose of each medication
  • agreed instructions on how to handle anticipated emergencies
  • key contacts (eg community nursing service and GP phone numbers)
  • advance care planning documents.

Medicare subsidies may be available for case conferences to plan and communicate management decisions, and also for treatment plans and allied health services.