Editorials

Routine integration of palliative care:

what will it take?
Palliative care is an essential component of quality care in advanced illness

P
“our society alliative care has substantial benefits for patients increasing frequency of admissions, or the development
with advanced disease, including improved of a nominated disease complication such as metastatic
determinedly symptom relief, quality of life, and communica- disease, may offer an administrative prompt that occurs
avoids tion around health care goals.1 These benefits extend to routinely and requires a response, rather than initiation,
discourse the patient’s family,2 improving caregiver quality of life by the physician.
and bereavement outcomes.3 Palliative care is also asso-
around dying, ciated with cost savings with reduced hospitalisations
Once recognised, there remains the task of commu-
nicating with the patient and family around issues of
focusing and emergency department presentations, and greater
likelihood of death at home.1,4 worsening disease, disability and death. Yet, our society
instead on determinedly avoids discourse around dying, focusing
‘staying Despite these proven benefits, there is variability in access instead on “staying positive” and “fighting hard”. The
to palliative care and many patients are not referred in a media reinforces this language and focus, offering few
positive’ and timely manner. Although 62% of patients with metastatic stories of those whose illness progresses. This silence is
‘fighting hard’” lung cancer in Victoria are engaged with palliative care also present in the clinic, and so instead we frequently
services by the time of death, most are referred in the find it easier to offer a further round of treatment rather
final hospital admission, during which they die.5 These than discuss the implications of failure of the last. By
patterns are reflected nationally and internationally, failing to engage patients and their families in such dis-
with a median survival following admission to palliative cussion until death is imminent, we limit opportunities
care programs of 22–54 days,3,6 suggesting late referral. of patients to realise choices in the final phase of life.
The timing of referral to palliative care or adoption of a Given these significant barriers, how do we promote
palliative approach appears to be important in achieving palliative care to patients and their families? Perhaps
benefits.2,4,7 Late referral leaves little time to establish patients themselves offer the solution. When asked,
confidence in community-based care, or to undertake patients are clear about what is important at the end of
complex communication tasks, such as exploring val- life, and much of this revolves around successful com-
ues and establishing goals for care. Barriers to timely munication and subsequent planning.13 They want a
engagement with palliative care include limitations in holistic approach to their care that embraces their hopes
workforce and service models, availability of services, for living even as they die. They want to be free of pain
failure to recognise poor prognosis or patient needs, and and other symptoms, so that they may realise goals in the
fear of destroying hope or upsetting patients.8,9 Indeed, personal realm. Palliative care represents a philosophy of
when referral to palliative care is raised, some patients are care that facilitates these goals and should be explained
distressed but they also report interest in its components, to patients in these terms, as a set of practices oriented
namely access to symptom control, psychological and towards achieving their nominated wishes.
family support, and assistance with decision making.10
Bereaved carers report a wish for earlier engagement Successful integration of palliative care in the future will
with palliative care in their relative’s illness.11 therefore require not just access to quality services, but
also recognition of the final phase of life and a willing-
So how may we improve routine integration of palliative ness by physicians to have this difficult conversation
care in advanced illness? A whole-of-system approach has with patients. This conversation should include a careful
been advocated, involving quality-improvement strategies exploration of the patient’s understanding of the disease,
that identify and respond to specific gaps in care, coupled a discussion of possible outcomes, establishing the goals
with measures of achievement and accountability.12 of care, and then, as appropriate, an explanation of tasks
Yet, even in systems without barriers to palliative care,
Jennifer Philip of palliative care and how these might be relevant to these
PhD, FAChPM, MMed there remain two clinical tasks that appear critical to its
goals. Without engagement with this communication, any
successful integration: recognition of the possibility (and
Anna Collins future possibility for integrated quality care based on
MHealthPsych, BSci(Psych) need) for palliative care, and sensitive communication.
patients’ preferences for the end of life will likely be lost.
St Vincent’s Hospital, A number of prompts have been proposed to ensure the
Competing interests: No relevant disclosures.
Melbourne, VIC. task of recognition occurs. These include disease specific
jennifer.philip@svha. prognostic tools, measures of need both symptomatic Provenance: Commissioned; externally peer reviewed. 
org.au and psychosocial, and clinical prompts such as “would © 2015 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
I be surprised if this patient died in the next 6 months?”.
doi: 10.5694/mja15.00994 An alternative approach based on service use, such as References are available online at www.mja.com.au.

MJA 203 (10) · 16 November 2015

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Editorials

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