PALLIATIVE CARE INDEX 1 DEFINITIONS 2 GUIDANCE 21 SUPPORTIVE

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Palliative care – general principles




PALLIATIVE CARE




Index




1. Definitions


2. Guidance

2.1 Supportive care and general palliative care

2.2 Specialist palliative care


3. References








Palliative care – general principles

1. Definitions

Supportive care is defined as care that helps the patient and her family to cope with cancer and treatment of it – from pre-diagnosis, through the process of diagnosis and treatment, to cure, continuing illness or death and into bereavement. It helps the patient to maximise the benefits of treatment and to live as well as possible with the effects of the disease. It is given equal priority alongside diagnosis and treatment (National Council for Hospice and Specialist Palliative Care Services, 2002).

Palliative care is defined as the active holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments (National Council for Hospice and Specialist Palliative Care Services, 2002).

The term palliative care encompasses both general palliative care and specialist palliative care.


General palliative care is a core aspect of care for all patients and their families with advanced cancer. It includes the care provided by members of the site specific gynaecological-oncology team, general practitioners, community nursing staff, allied health professionals, and social work staff. It should include the provision of basic levels of symptom control, information to patients and families, psychological, social and spiritual support and open and sensitive communication with patients and their families. It also includes end of life care for dying patients. Providers of general palliative care should assess patients’ needs on a regular basis, and know when to seek advice from or refer to specialist palliative care (NICE, 2004).


Specialist palliative care is an integral component of the care of some patients with advanced cancer, required at varying times during their illness.

Specialist palliative care is defined as “the total care of patients with progressive, far advanced disease and limited prognosis and their families, by a multi-professional team who have undergone recognised specialist palliative care training”. It provides physical, psychological, social and spiritual support, and will involve practitioners with a broad mix of skills (NICE, 2004). These services are provided by statutory and voluntary organisations and cover community, hospice and hospital inpatient settings.

Specialist palliative care also provides an educational resource for other healthcare professionals.

2. Guidance

2.1 Supportive care and general palliative care

The General Medical Council has stated that every member of the medical profession requires generic palliative care skills (GMC, 2003). NHS Quality Improvement Scotland has set standards for the provision of both basic and specialist palliative care (Clinical Standards Board for Scotland, 2002). The National Institute of Clinical Excellence also offers guidance (NICE, 2004).

Supportive care and general palliative care should be part of the integral care provided by members of the site specific gynaecological-oncology team, general practitioners, community nursing staff, allied health professionals, and social work staff.

Supportive care and general palliative care is inclusive of, but not exclusive to, the following areas;


Basic symptom control should be initiated by those providing general palliative care. Symptom control guidelines, either local (Pan-Glasgow Symptom Control Algorithms in Cancer Care, 2005; The Lothian Palliative Care Guidelines Group, 2004) or national (Effective Health Care, 1994; SIGN, 2000) should be followed with clear indications for referral to specialist palliative care

services if symptoms are not rapidly controlled.






Information should be available to patients and care throughout the patient pathway. It should be high quality and targeted to the needs of individual patient groups (Berner et al, 1997; McPherson et al, 2001; Jones et al, 1999; Robinson et al, 1999; evidence level Ia-Ib).


The psychological wellbeing of patients should be assessed at key points in the patient pathway and all staff directly responsible for patient care and should offer patients general emotional support based on skilled communication, effective provision of information, courtesy and respect (Devine and Westlate, 1995; Meyer and Mark, 1995; evidence level Ia-IIb).

Patients with significant levels of psychological distress should be referred to services able to provide specialist psychological care (Greer et al, 1992; Moorey et al, 1998; Sheard and Maquire 1999; evidence level Ia-Ib).

Social and spiritual needs of patients should be assessed and met appropriately, and be accessible from both the community and the acute sector (Seigal et al, 1992; Derin and Stygall 1997; Bloom et al, 1998; evidence level Ia-IIa).


Communicating significant news to patients should normally be undertaken by senior member of the multidisciplinary team who is an effective communicator (Stewart, 1996; Baker et al, 2000; evidence level Ia).

All members of the gynae-oncology multidisciplinary team should have access to communication skills updates/courses (Jenkins and Fllowricked, 2002; Fellows et al, 2003; evidence level Ia-IIb).


Cancer rehabilitation attempts to maximise patient’s ability to function, to promote their independence and to help them to adapt to their condition (National Council for Hospice and Specialist Palliative Care Services, 2000).

Rehabilitation services are provided by a range of allied health professionals and others including appliance officers, dieticians, lymphoedema therapists, occupational therapists, oral health specialists, physiotherapists and psychosexual counsellors.

Rehabilitation needs of patients should be assessed and identified throughout the patient pathway and appropriate referrals made (NICE, 2004).


Patients with a gynaecological malignancy who are dying have their needs identified and addressed. The Liverpool Care Pathway for the Dying Patient provides one mechanism for achieving this (Ellershaw et al, 2001; evidence level III).


2.2 Specialist palliative care

Involvement of specialist palliative care is associated with patients spending more time at home, greater satisfaction amongst patients and carers, better symptom control, a reduction in the number of inpatient hospital days, a reduction in overall cost and an increase in the number of patients dying where they wished (Hearn and Higginson, 1998; Ellershaw et al, 2001; Hanks et al, 2002; Salisbury et al, 1999; evidence level Ia-III).

Specialist palliative care includes all of the areas mentioned already under supportive care and general palliative care. The timing of referral for specialist palliative care will therefore depend on the experience and expertise of the gynaecological oncology team in general palliative care, as well as the complexity of the patient’s needs.




3. References


Baker R, Wu AW, Teno JM, et al. (2000) Family satisfaction with end of life care in seriously ill hospitalized adults. J Am Geriatrics Soc, 48, Suppl 9.


Berner ES, Partrisdge EE, Baum SK. (1997) The effects of the PDQ patient information file (PIF) on patient’s knowledge, enrolment in clinical trials and satisfaction. J Cancer Education, 12, 121-5.


Bloom JR, Ross RD, Burnell G. (1998) The effect of social support on patient adjustment after breast surgery. Patient Counselling Health Education, 21, 320.


Clinical Standards Board for Scotland. (2002) Clinical standards: specialist palliative care revised education. The Board. Edinburgh.


Derin S, Stygall J. (1997) Does being religious help or hinder coping with chronic illness? A critical review. Pall Med, 11, 291-9.


Devine EC, Westlate SK. (1995) The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies. Oncol Nursing Forum, 22, 1369-81.


Effective Health Care. (1994) Implementing clinical guidelines: can guidelines be used to improve clinical practice? University of Leeds.


Ellershaw J, Smith C, Overill S et al. (2001) Care of the dying, setting standards for symptom control in the last 48 hours of life. J Pain Symptom Management, 21, 12-7.


Fellows D, Wilkinson S, Moore P. (2003) Communication skills training for health care professionals working with cancer patients, their families and/or carers. (Cochrane Review). The Cochrane Library.


General Medical Council. (2003) Tomorrow’s doctors. Recommendations on undergraduate medical education. The Council. London.


Greer S, Moorey S, Baruch JD et al. (1992) Adjuvant psychological therapy for patients with cancer, a prospective randomised trial. BMJ, 304, 675-80.


Hanks GW, Robbins M, Sharp D et al. (2002) The ImPaCt Study: a randomised controlled trial to evaluate a hospital palliative care team. Br J Cancer, 87, 733-9.


Hearn J, Higginson IJ. (1998) Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review. Pall Med, 12, 17-32.


Jenkins V, Fllowricked L. (2002) Can communication skills training alter physicians beliefs and behaviour in clinics? J Clin Oncol, 20, 765-9.


Jones R, Pearson J, McGregor S et al. (1999) Randomised trial of personalised computer based information for cancer patients. BMJ, 319, 1241-7.


Meyer TJ, Mark MM. (1995) Effects of psychosocial interventions with adult cancer patients; a math analysis of randomised experiments. Health Psychol, 14, 101-8.


McPherson C, Higginson I, Hearn J. (2001) Effective methods of giving information in cancer; a systematic literature review of randomized controlled trials. J Public Health Med, 23, 227-34.


Moorey S, Greer S, Bliss J et al. (1998) A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer. Psycho-oncology, 7, 218-28.


National Council for Hospice and Specialist Palliative Care Services. (2000) Fulfilling Lives. Rehabilitation in Palliative Care. NCHSPCS. London.


National Council for Hospice and Specialist Palliative Care Services. (2002) Definitions of supportive and palliative care. The Council. (Briefing paper II). London.


NICE. (2004) Improving Supportive and Palliative Care for Adults with Cancer.


Pan-Glasgow Symptom Control Algorithms in Cancer Care. (2005).


Robinson JW, Faris PD, Scott CB. (1999) Psychoeducational group increases vaginal dilatation for younger women and decreases sexual fears of women of all ages with gynaecological carcinoma treated with radiotherapy. Int J Rad Oncol Biol Physics, 44, 497-506.


Salisbury C, Bosanquet N, Wilkinson EK et al. (1999) The impact of different models of specialist palliative care on a patient’s quality of life: a systematic literature review. Pall Med, 13, 3-17.


Scottish Intercollegiate Guidelines Network. (2000) Control of pain in patients with cancer. SIGN. Edinburgh.


Seigal K, Mesagno FP, Kanis DG et al. (1992) Reducing the prevalence of unmet needs for concrete series of patients with cancer. Evaluation of a computerised telephone outreach system. Cancer, 69, 1873-83.


Sheard T, Maguire P. (1999) The effect of psychological interventions in cancer patients: results of two meta-analysis. Br J Cancer, 80, 1770-80.


Stewart MA. (1996) Effective physician – patient communication and health outcomes: a review. Can Med Assoc J, 152, 1423-33.


The Lothian Palliative Care Guidelines Group. (2004) Lothian palliative care guidelines. 2nd Edition.


North Wales Cancer Guidelines, Palliative Care (June, 2008) 5


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