Introducing a patient to palliative care

Many people live for a long time, often years, after the diagnosis of a life-limiting illness. Some patients decline the offer of potentially life-prolonging treatment (eg chemotherapy, dialysis) and instead opt to focus on quality of life at the time of diagnosis. Others may not accept the inevitability of death even when all conventional therapeutic options have been exhausted. Between these extremes, there are many ways that to integrate a palliative approach to care while maintaining hope for life prolongation or even cure.

The timing of the integration of a palliative approach to care is influenced by many factors, including:

  • the nature of the patient’s disease
  • the acceptability and effectiveness of the treatment available
  • the patient’s beliefs and cultural values regarding illness, dying, and social roles and expectations
  • the patient’s frailty or functional status, and the presence or absence of comorbidities
  • family and other responsibilities.

It is often appropriate to introduce palliative care from the time it is recognised that a patient has a progressive, life-limiting illnessFerrell, 2017Higginson, 2014Temel, 2010. This allows supports to be put in place and symptoms to be addressed early. The patient can take time to consider their life goals, values and preferences and discuss emotional issues with healthcare professionals, families and carers. Early discussions can help patients to feel more secure, knowing that they will be supported whatever happens.

Note: It is often appropriate to introduce palliative care from the time it is recognised that a patient has a progressive, life-limiting illness.

Various strategies have been developed to assist clinicians to identify patients who are likely to benefit from advance care planning and integration of palliative care. One strategy is for the clinician to ask themselves the ‘surprise question’—’Would I be surprised if this patient were to die in the next 6 to 12 months?’ If the answer is ‘no’, it may be timely to review the patient’s situation and needs, and start planning future care.

For a patient with refractory disease, consider reviewing goals of care, discussing advance care planning, and involving a palliative care team. In general, consider palliative care input when the patient:

  • has poor or deteriorating performance status and reversibility is limited
  • is in bed or a chair for 50% or more of the day
  • is dependent on others for most care needs due to physical or mental health problems
  • has had 2 or more unplanned hospital admissions in the last 6 months
  • has had significant weight loss (5 to 10%) over the last 6 months or has a low body mass index
  • has persistent troublesome symptoms despite optimal management of underlying condition(s)
  • asks for supportive symptom management or treatment withdrawal.

The Supportive and Palliative Care Indicators Tool (SPICT) is a clinical prognostication tool used to assess general indicators of deteriorating health (similar to those outlined above) and indicators for specific conditions (including cancer, dementia, kidney disease)SPICT, 2022. For further information, see the SPICT website.

Healthcare professionals are in the best position to approach or facilitate discussions about the introduction of palliative care. However, these discussions can be difficult and confronting for the patient and their family; skill and patience are required—see Communicating with and supporting patients with palliative care needs.

Most patients with a life-limiting illness appreciate acknowledgement and validation of the changes they are experiencing, however distressed they may become at the time. Questions that a healthcare professional may use to open such a discussion are:

  • Can you tell me what you understand is going on with your [insert disease], and do you have any questions about it?
  • What changes in your condition have you noticed recently?
  • Many people worry about what might be happening to them. Are there any particular issues that you are worrying about or fearful of?
  • Are there any issues that you would like to discuss?

Patients with a life-limiting illness may become seriously ill on several occasions, only to recover for a significant but unpredictable period; this uncertainty can be stressful for the patient and their family. The use of drug therapy and other modern technologies can prolong dying, rather than sustaining life with quality. Discussion about which interventions are acceptable to a patient should be considered in advance care planning, preferably while the patient is well enough to participate in discussions and before decision-making becomes urgent.