Issue 2 • 2021
Palliative medicine, respiratory medicine and integrated care
Elderly man lying in a hospital bed and coughing
The RACP strongly promotes the value of integrated care for both patients and physicians. One of the many areas where more integrated care would make a difference is in treating patients with respiratory illnesses.
For people with non-cancer, long-term respiratory conditions, the healthcare system generally does not facilitate referral to palliative care consultation, as opposed to people with cancer conditions. This can mean that people with life-threatening, but non-cancer illness are less likely to receive specialist palliative care than those with cancer, despite similar levels of suffering.
The availability of specialist palliative care is important in these circumstances to enable people to improve symptom control, discuss wishes and possibilities, meet unmet needs, and to help them explore their own goals for the future, whatever that might hold.
Chronic conditions do pose challenges for community-based healthcare services regarding co-morbidities and associated changes in both function and symptom burden.
People with long-term respiratory conditions and their families have made their feelings known in this regard, and while it is unusual for discussions not to occur within primary care or respiratory medicine, the patient’s perspective is important.
Whatever I know about it, it’s something I’ve learned, I haven’t been told. Nobody’s ever said, “Sit down here, you have emphysema, and this is going to happen to you.” (Patient) “Looking back if we had end-of-life discussions 12 months earlier, we could have prepared (for John’s death) – it happened so much quicker than we expected.” (Relative) “You know you've got this disease that's wearing your lungs out, but no one explained to you how long you've got." (Patient)
The concept of ‘respiratory supportive care’ focuses on needs assessment in terms of symptom burden, advance care planning, and family support within a shared care plan across specialties and primary care. This provides an extra layer of care but does not replace primary care or specialist respiratory medicine.
Dr Meg Sands FAChPM, a palliative supportive care physician and member of the Australia and New Zealand Society of Palliative Medicine (ANZSPM), is familiar with this situation. She would like to see an integrated care strategy to improve the level of patient access to supportive palliative care in respiratory medicine.
As a result of Dr Sands and ANZSPM bringing this to the attention of the College Policy & Advocacy Council (CPAC), the College Policy & Advocacy Unit is exploring better approaches to the integration of respiratory and palliative medicine expertise. The College has advocated for specialist services to be better interconnected with primary care, and for models of care to support patient access to physicians in ambulatory telehealth and outreach settings.
“Patients with respiratory illness need more access to quality care throughout the illness trajectory and across care settings,” she says.
“The College can make a difference here through its leadership in integrated care to enhance collaboration between specialties including primary care. We need to promote improved organisation of care delivery within the healthcare system.”
In the matter of safe, high-quality care, higher levels of coordination of care are needed. This would reduce or streamline Emergency Department presentations. The hospital sector would benefit from targeted admissions and interventions through more effective symptom management in the community.
“To begin with, we need a better process for comprehensive needs assessments,” suggests Dr Sands.
Each state and territory have different approaches to providing palliative care related services.
One approach that incorporates respiratory and palliative medicine is the Advanced Lung Disease Service (ALDS) at the Royal Melbourne Hospital.
A published study describes a 52.4 per cent reduction in the mean number of emergency department respiratory presentations in the year after ALDS care commenced. There were other positive outcomes such as 84.8 per cent of patients having discussed and/or completed an advance care plan. Of the 61 patients who died over the evaluation period, only 15 (24.6 per cent) died in an acute hospital bed. The study demonstrates that integrated respiratory and palliative care is associated with improved end-of-life care and reduced unscheduled healthcare usage.
There are guidelines recommending specialist palliative care for patients with advanced lung disease, yet in Australia, only 17.9 per cent of Chronic Obstructive Pulmonary Disease (COPD) patients access any palliative care in their last year of life, and 72 per cent of COPD patients die in an acute hospital bed. By contrast, in Melbourne’s ALDS cohort, three-quarters of patients died outside of an acute hospital bed, with half of those patients dying with community palliative care support or in a dedicated palliative care ward or hospice.
“I would like to see the involvement of primary care, respiratory medicine and palliative and supportive care in such situations because it allows for delivery of a comprehensive service that provides safe multidimensional care to best support people with long term respiratory conditions.
“More than ever, we need to consider people in the community of any age group with chronic conditions, organising access to the right care in simpler ways so patients are receiving the appropriate expertise,” says Dr Sands.
© 2021 The Royal Australasian College of Physicians