Service Delivery Flashcards
Areas of focus for improved delivery of palliative care
As per the WHO:
- Improved drug availability
- Education
- Policy development
- Quality of care
- Research
Social barriers to access to palliative care
- Not defined as a human right, and is rather a principle available to the few
- Global barriers
- Just 15% of countries have an integrated palliative care service
- Not yet defined as a human right - Economic barriers
- Access to basic healthcare is a barrier for many
- Aging population, rising costs, increasing global demand on healthcare services due to chronicity
- PC may not be a funding priority - Drug availability
- Access to opioids may be limited by legal methods
- Drug cost can be an issue
- Providers may be reluctant to prescribe opioids - Ethnicity
- Uptake of palliative care services by patients in ethnic minorities is less
- Services may struggle to deliver culturally appropriate care
- Patients may lack understanding of the role of hospices
- Communication barriers - Elderly
- Many elderly patients in LTC do not have access to palliative care
- Barriers include delivery system barriers, financial issues, and regulatory factors
- Link nurses in LTC may be helpful - Homelessness
- Difficulty in providing reliable care
- Chronic health problems, increased incidence of trauma
- Illicit drug use and lack of trust - Community barriers
- Community HCPs play a significant role, but many are unwilling or unable to provide home visits
- Advanced care planning may not occur for a variety of reasons, including time management, prognostic uncertainty, limited collaboration with secondary care - Incarceration
- Prison population is also aging, and an increasing number will die in prison
- Social determinants may play a significant issue
- Social supports for optimal care often unavailable
Professional barriers to palliative care
- Attitudes
- ‘Learned helplessness’ amongst oncologists where there is ineffective medication to manage symptoms
- Reluctance to refer
- Fear of palliative care resulting in a patient no longer engaging in life prolonging treatment - Knowledge
- Education regarding symptom management, role confusion, and whether PC is appropriate for non-malignant disease
Barriers to palliative care in key disease groups
- Cardiac
- Underused, despite evidence supporting its importance in symptom management
- Prognostic uncertainty - Respiratory
- Lack of evidence and guidelines, yet patients have significant symptoms
- Reluctance to negotiate EOL decisions in patients and families - HIV/AIDS
- Prognostication is difficult
- Communication may be challenging, especially in terms of the rapport needed to discuss EOL
- Stigma towards LGBTQ+ status or substance abuse - Renal failure
- Prognostic difficulties
- Infrequent palliative care input to dialysis patient, despite clear needs
Main disease groups identified as needing/being eligible for palliative care in Canada (CSPCP)
- Advanced cancers
- End stage organ failure (heart, lung, kidney, liver)
- Neurodegen diseases (ALS, Huntington’s, AD, MS)
Model of palliative care (pyramid model) according to need
- Community supports (base)
- Social aspects of care not provided by the healthcare system
- E.g. financial support through compassionate leave/EI, bereavement support through volunteer groups and society, family care - Primary Palliative Approach to Care
- Patients who will require care within the scope of primary care (provided by non-palliative care specialists, GPs, nurses, etc.) with appropriate training and support - Specialist Palliative Care
- Care for those with needs not met by PCP and non-palliative care specialists
- Provided by either enhanced primary palliative care (e.g. non-specialists with additional training in palliative care) or a palliative care specialist physician (less available and must be allowed time and resources to train and support colleagues in other disciplines to develop capacity) - (side of the pyramid): Patients who would not be eligible for palliative care (e.g. sudden death) - will never require even primary palliative approach to care, but their family will require community supports (#1) through the bereavement process
Components of a specialist palliative care service
- Direct care to complex patients and families
- Provide education and support to generalists
- Untertake or collaborate in research to improve care of patients and families in the future
Joint models of palliative care provision
- Relatively new models
1. Early integrated palliative care with oncology (at the time of diagnosis)
2. Breathlessness clinic with palliative and COPD
Previously, palliative care only begin once curative treatment stopped, whereas now palliative care overlaps with curative treatment, with palliative care being a large component over time
Definition of Palliative Care Unit
- Department specialised in the treatment and care of palliative care patients
- May be standalone (eg. inpatient hospice) or part of a hospital.
Goal:
- Alleviate disease and therapy-related discomfort
- Stabilize patient status
- Provide patient and carers psychological and social support in such a way that may allow for discharge or transfer to another care setting
Palliative Care Hospital Consultation Teams
- Provide specialist palliative care advance and support to other clinical staff, patients, families, and carers in the hospital environment
- Part of job is formal and informal education and liaison with other services
- Core aim is symptom management
Palliative Care Home Care Consultation Teams
- Provide specialist palliative care in the home
- Support families
- Provide specialist advice to family docs, nurses, others providing home care
- May either take over from GP or advise GP
- Increases odds of dying at home (doubles)
Palliative Care outpatient services
- Clinics where patients can receive PC consultation
- May be offered jointly with oncology/resp/neuro etc.
- Meet the need to integrate services and may introduce patients to PC earlier, in a non-threatening way
Palliative Care Day care
- Day hospices
- Designed to provide additional support to patients in the community and their families
- Typically patients are only eligible if they are already under the care of the home palliative care team at that centre
Short term-integrated palliative care
- In general, PC has seen patients and ‘kept’ them until they died (even if not as an inpatient)
- Given earlier integration of PC and longer trajectories of some disease, allows a service to see a patient and assess, provide recommendations, then discharge back to other service
Professionals involved in a Palliative Care Team
- Specialist PC physician
- RNs
- Social workers
- Pharmacists
- PT
- OT
- Psychology
- Chaplain