The Difference
Palliative Care Makes is
More than Just Caring
for the Whole Person
Professor Richard Chye
Adjunct Professor of Medicine, UNDA
Director, Sacred Heart Supportive & Palliative Care
St Vincent’s Hospital, Sydney
Acknowledgements &
Conflicts of Interest
Richard Chye has received educational and research grants from
• Boehringer Ingelheim
• Link Pharma
• Mundipharma
• Menarini
• Teva Pharmaceuticals
Richard Chye has been consulted by
• ACT Government Solicitor
• NSW Crown Solicitor
• University of Wollongong
Palliative Care
It does fulfil so many aspects of the
“Healing of Christ”
In our patient (and family) centred
care & support of the
Sick
Vulnerable
Destitute
But Do We Have To Be Dying
to Get Good Compassionate Care
Changing Cancer Care Paradigms
• New more tolerable chemotherapy drugs
–
–
–
–
Less nausea
Less deconditioning
Less need for reconditioning (Cancer Rehab)
Given Closer to Death
• Patient Demand
• Better supportive drugs
– Anti-nauseants
– Growth Factors
• More chemo-radiation regimes
Contemporary Anticancer
Treatment
Active Treatment
Palliative Care
Anticancer treatments are becoming more tolerable
more orally administered chemotherapy
less side effects from modern chemotherapy
better drugs to control side effects
Contemporary Anticancer
Treatment
Active Treatment
Palliative Care
Palliative anticancer treatments are being
given later in the trajectory of disease,
closer to death.
Place of Death of Patients Know to Palliative Care Services in South
Eastern Sydney (Excluding Calvary Hospital & Illawarra)
60%
Hospices
Hospitals
Home
50%
40%
30%
20%
10%
0%
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Because more patients are being treated
closer to their death….
…..palliative care more than ever needs
to be part of acute hospital care
Supportive Care
Palliative Care now supports patients
undergoing palliative anticancer
treatments
Can we also offer the same expertise to
patients undergoing curative treatments?
Sacred Heart
Supportive & Palliative Care
Inpatient Care at Sacred Heart
• Radiotherapy even for those with curative
intent
• Reconditioning
• Uncomplicated febrile neutropenia
• 39 inpatient beds (down from 100 in 1995)
Sacred Heart
Supportive & Palliative Care
Community Outreach
at Sacred Heart
Sacred Heart Inpatients
Percentage of Deaths Within 2 Days of Admission
22%
20.0%
21%
19%
18%
18%
16.5%
15%
15.0%
9.9%
10.0%
8.4%
5.0%
2.0%
1.4%
0.0%
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Care at Home in the
Last Few Days of Life is Hard
A Dying Patient becomes
• Confused as he/she become sick & lethargic
• More delirium at night – Poor sleep
• More Bed Bound, therefore more incontinence
Therefore the need for admissions close to death
Personal Care Packages
• Sacred Heart in partnership with Calvary
Health, Kogarah and Hammondcare
• Care Packages at Home when the terminal
phase is identified
• With family’s permission, carers provide
personal care in the last 48 hours (and
extendable for another 48 hours)
Improved Sacred Heart’s dying at home
rate from 20% to 40%
Do our health systems
promote compassionate care?
Are we scared of
providing compassionate care
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
Are we prevented from
providing compassionate care
“She is ONLY allowed a
certain amount”
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
Do we make our families angry?
“Please can she some more?”
“NO”
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
Andrew Denton
used this as an argument to
legalise Euthanasia!!
Are We??
Palliative Care
IS
DIFFICULT
“It’s not nice to watch”
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
Nothing works and
it’s horrible to watch
“It is the toughest part
of your job”
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
The Stress of Looking After a
Dying Patient
“…feel I have not achieved….”
Andrew Denton Series of Podcast from The Wheeler Centre
http://www.wheelercentre.com/broadcasts/podcasts/better-offdead/10-neither-hasten-nor-prolong-death
Support for Staff who work in
End-of-Life Care
Sacred Heart provides a systematic
program of clinical supervision and
debriefings for doctors, nurses and allied
health.
Started by Prof Peter Ravenscroft at
Calvary Mater Newcastle
National Safety & Quality
Health Standards (NSQHS)
Standard RH: Reducing Harm
RH7 End-of-Life Care
• Systems are used to identify consumers at
the end of life, and to provide safe and highquality care.
National Safety & Quality
Health Standards (NSQHS)
RH7.3 Where end-of-life care is provided,
the health service organisation has systems
that:
c. provide access to supervision and
support for clinicians delivering end-of-life
care
What is Patient-Centred Care?
What is Patient-Centred Care?
Is it not based on what a patient wants, and
what a patient does NOT want?
National Safety & Quality Health
Standards (NSQHS)
Standard CC: Comprehensive Care
National Safety & Quality
Health Standards (NSQHS)
Standard CC: Comprehensive care
• Ensure that consumers receive …health care
that is based on identified goals... These
goals are aligned with the consumer’s
expressed preferences & healthcare needs,
consider the impact of the consumer’s
health issues on their life and wellbeing,
and are clinically appropriate.
CC6.1 Clinicians develop & document an
integrated & individualised care plan that:
a. Considers the consumer’s preferences,
personal circumstances and information
from carers
b. strategies and actions for managing
identified clinical risks
c. clearly articulated goals for the consumer’s
episode of care
The consent process
• 91 year old who lives alone, independent
with ADLs, nil mobility aids.
• Has AF, hypertension, anxiety, osteoporosis
• Fell out whilst coming out of taxi
• Presented with left elbow and hip pain
• Found to have fracture left elbow, hip and
pelvis
• Consent for operative management
Before we start to operate,
what are the likely outcomes?
• What is her chance of returning home
living independently?
• What is her chance of being placed in
a RACF?
• What is her chance of dying during
this admission?
What did Rogers v Whitaker (1992)
teach us (for a 1 in 14000 risk)?
• …the law should recognise that a doctor has
a duty to warn a patient of a material risk
inherent in the proposed treatment;
• “the paramount consideration that a person
is entitled to make his own decision about
his life”
http://www.austlii.edu.au/au/cases/cth/HCA/1992/58.html
If we answered
“greater than 10%”
to any of these questions,
should we not explain that to
the patient as part of the
consent process?
Amber Care Bundle
http://www.cec.health.nsw.gov.au/programs/amber-care
Amber Care Bundle
It encourages clinicians, patients and families
to continue with treatment, if they wish, in the
hope of a recovery, whilst talking openly
about preferences and wishes, and putting
plans in place in preparing for end of life.
Hope for the best, plan for the worst
http://www.cec.health.nsw.gov.au/programs/amber-care
Thank You