Advance care planning (ACP) improves palliative care and end-of-life outcomes for patients, families, clinicians and the healthcare system. However, uptake remains low with substantial variation existing across organisations and health sectors. Notwithstanding set ACP criteria and measures in quality standards, there are limited dedicated ACP audit and improvement tools available to organisations. During 2017-19, the Prevalence of ACP documentation in Australian Health and Residential Aged Care Services study supported a limited number of participating sites to collect audit data and report gaps.  

Aims 

To improve ACP implementation and practice within health and aged care services by adapting prevalence study resources into an ACP improvement toolkit. This project aims to understand evidence relating to ACP quality improvement, existing toolkits and stakeholders’ preferences to inform the development of an ACP improvement toolkit. 

Methods 

A systematic environmental scan and rapid literature review were undertaken to identify existing ACP improvement toolkits and describe the evidence. National sector and ACP expert consultations were undertaken to obtain stakeholder preferences and advice.    

Findings 

The environmental scan revealed eighteen palliative care toolkits, three specifically ACP-related. The literature review found only four published studies inclusive of ACP quality improvement tools, with only one solely dedicated to ACP. 

National consultation provided support for this initiative, identifying this work as a known gap. The toolkit was acknowledged as aligning with other palliative care reform and as a valuable source of measurement and evidence to assist organisations with quality improvement. Consultation revealed that consideration needs to be given to the availability and capability of the workforce, ongoing consultation and evaluation. It was advised that the toolkit should be voluntary, easy to use and contain optional components. 

These findings demonstrate the need and feasibility of an ACP improvement toolkit to improve ACP implementation and practice within Australian health and aged care services.  

Palliative radiotherapy (PRT) is commonly used for symptom control for locally advanced and metastatic cancers. It can be associated with significant side effects in the short term that impact quality of life. These may outweigh the benefits where prognosis is poor. Early involvement of specialist palliative care (SPC) services helps focus on maximising symptom control and maintaining quality of life.

Methods:

Information was gathered from the electronic medical records (EMR) of 645 patients who had commenced PRT over a six-month period across three sites of a national radiation oncology centre in the Republic of Ireland. We explored survival time post completion of radiotherapy and referral to SPC services. Additional information was obtained from the patients’ GPs and online resources (RIP.ie).

Notably, 15.8% (n=102) of all patients died within 30 days of completion of radiotherapy and of these, 45% (n=46) were not referred to SPC services. Patients in this subgroup had markers of frailty and only 26.4% (n=27) had a recording of performance status on the EMR. We were unable to obtain complete data for 12.4% (n=80) patients. At the time of data collection, 11.6% (n=75) of patients were still alive. 

Our data is in line with previous studies of this nature. Prognostication is difficult, but we must be careful when selecting candidates with advanced disease for palliative RT to avoid additional symptom burden. Referral should be made to SPC services where available.

Palliative patients are often on complex medication regimes to manage their symptoms and comorbidities and are therefore at high risk of medication-related problems. Pharmacists have the skills to work within a multiprofessional team to conduct medication management reviews for these patients.

The aim of this study was to evaluate a pharmaceutical telehealth service involving medication management support to community palliative patients and their carers.

Patient demographic data collected included age, gender, primary and secondary diagnoses and level of function. Data from the medication management review included prevalence of polypharmacy, number of inappropriate medication as per the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) and recommendations on deprescribing, symptom and medication management.

Data was collected over a 6-month period, October 2020 to March 2021. In total 89 patients participated in the pharmaceutical telehealth service. The mean age was 75 years (median 76 years): six between 51-60, 23 between 61-70, 29 between 71-80, 26 between 81-90 and five over 91; 37 were female and 52 males. Whilst 75 patients had a cancer diagnosis, 14 had non-cancer diagnoses that included end stage cardiac, respiratory and renal failure and multiple sclerosis. 

At referral, 80 patients were taking five or more medications with 50 taking 10 or more medications. Applying the STOPPFrail criteria, 44 (49.4%) patients were taking inappropriate medication. Overall, 126 recommendations were accepted from the medication management review. 

This study provided evidence regarding the value of including a pharmacist in palliative care telehealth programs. The pharmaceutical review demonstrated the complexity of medication regimens used by palliative care patients, the utility of the pharmaceutical telehealth review and the acceptance of these recommendations by the treating team. The introduction of a pharmaceutical telehealth service improved community palliative care patients’ symptoms and medication management. 

Palliative care in Australia has a system to support quality in specialist palliative care.  The existing National Palliative Care Standards 5th Ed. 2018  (NPCS) promote a vision for a compassionate and appropriate approach to specialist palliative care and provide a benchmark for person-centred, age-appropriate care.  Alongside the NPCS, the National Palliative Care Service Development Guidelines provide an overarching framework for high quality specialist palliative care delivery. 

 

The medical management and coordination of care for people living with a life-limiting illness may be undertaken by a wide range of healthcare professionals across a broad range of service settings. To acknowledge that a significant proportion of palliative care occurs in the primary care setting and by non-palliative care specialists, Palliative Care Australia is developing the NPCS: Generalist Supplement.  These standards for generalist palliative care aim to strengthen the foundations for high quality generalist palliative care and, where available, timely transitions to specialist services.

The Generalist Supplement are evidence-informed and have been developed to sit parallel to the National Palliative Care Standards 5th Ed. 2018  (NPCS) and uses the same framework.  A comprehensive consultation process has also enabled input from those working in specialist palliative care, alongside the views of those health professionals who are ‘generalists’ with respect to palliative care, notwithstanding that many of them might be specialists in their own discipline.

The Generalist Supplement is for primary care specialists and providers such as general practitioners, physicians, nurses, social workers, physiotherapists, occupational therapists, speech-pathologists, pharmacists, and spiritual workers.  It also supports non-palliative care specialists such as geriatricians, physicians, oncologists, paediatricians, renal specialists, cardiologists, endocrinologists, and other specialists.  

The Generalist Supplement provides guidance on quality, evidence-based, person-centred palliative care across generalist settings, regardless of setting.