CA -- eLetters for Finlay and Casarett, 59 (4) 250-263

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Esmé Finlay and David Casarett
Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice
CA Cancer J Clin 2009; 59: 250-263 [Abstract] [Full text] [PDF]

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Palliative Cancer Care – An Australian Perspective: Deborah M Creaser (23 September 2009)

Palliative Cancer Care – An Australian Perspective 23 September 2009

Deborah M Creaser,
Radiation Therapist
Monash University
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Re: Palliative Cancer Care – An Australian Perspective

deborahcreaser{at}aol.com Deborah M Creaser

Remarkable similarities exist between the SPIKES Protocol, developed in the U.S. by E. Finlay and D. Casarett, providing an organised framework for prognostic conversations [1], and Clinical Practice Guidelines for Communicating Prognosis and End of Life Issues [2], developed in Australia. This presents an opportunity to share a perspective of palliative care, which considers the challenges faced in Australia.
More than 42,000 people are expected to die from cancer in Australia in 2009 [3]. Cancer is a leading cause of death in Australia, and in Victoria cancer accounts for 30% of all deaths [3].
High-level government support for palliative care initiatives in Australia has increased over the past two decades [4], perhaps indicative of the increased importance given to the care of the chronically ill and the dying and the realization that the needs of these patients were not being met.
More recently, the Victorian State Government stated its commitment to improving palliative care services in Victoria’s Cancer Action Plan 2008-2011, setting a target to increase the funding of supportive care, palliative care, and survivorship services by 50 percent by 2012 [5]. Emphasis has been placed on increasing the use of specialist multidisciplinary teams and the expansion of palliative care services to give patients and carers real choice about end-of-life care.
In Australia there are a number of issues regarding the access, equity, equality, and appropriateness of cancer care, including those for palliative care services. In many ways we are experiencing difficulty in "Crossing the Quality Chasm" as described by the IOM [6]. In order to shape healthcare to ensure we can meet the future needs of our patients we must tackle and conquer today’s challenges.
Cancer patients living in remote areas have poorer outcomes than those living in metropolitan areas and have survival rates around eight percent lower than the national average [7]. Their access to specialized palliative care services is also more limited.
A report commissioned by Cancer Australia states a network of regional multidisciplinary cancer centres should be established in key locations, as currently patients have to travel large distances to reach services. This should also help ease the pressure on metropolitan centres [7]. Partnerships between rural and metropolitan services have been established through the Palliative Care Consortia, in order to facilitate this process.
Indigenous health presents unique challenges. Average life expectancy of indigenous Australians is up to 19 years shorter than for non-indigenous Australians [7] and as a population group in Australia they have the worst cancer outcomes [8]. Palliative care needs to be culturally sensitive to indigenous traditions and beliefs surrounding death and dying. Without tailored palliative care, medical interventions and health care professional interactions with the patient and their family could be inappropriate. Consumer participation in decision-making processes and compliance with treatment are also less likely, as described by Maddocks and Rayner [8].
Funding systems for health care in Australia differ greatly from the U.S. system. Medicare (Australia) funds the majority of public palliative care whether in the home, public hospital, rehabilitation centre, or hospice. Privately funded hospices are available to patients with health insurance, though in metropolitan Melbourne (Victoria) these facilities are few.
Victorian public hospices do not have a prognosis-related criteria for the admission of patients, though patients must have symptoms to eligible. Waiting lists for public hospice admission vary, though a waiting period of one week is not uncommon. Priority for hospice placement is given to patients residing at home.
For asymptomatic patients, ineligible for hospice admission and unable to cope at home, transfer to a rehabilitation facility may be necessary, especially if they have complex health care needs.
Medicare generally covers the cost of public hospice care for 4-6 weeks. After such time, transfer to home or a nursing home would be considered depending on quality of life and aged care assessments.
In the community, the palliative care service together with the patient’s General Practitioner (GP) form the core support team. In Victoria a free palliative care advisory service is available to support the patient and their carers at all times. Referral to a Radiation Oncologist for palliative radiation therapy is often instigated by the GP. Yuen et al [9] recognize the interactions between GPs and the staff of aged care facilities are of particular importance.
The Australian Government has proposed a National Primary Health Care Strategy [10]. This could provide a major health reform in Australia, the magnitude of which has not been undertaken before. Currently public opinion to this proposal is being gauged through a consultation process. In regards to palliative healthcare, the strategy supports improving continuity and coordination of care through a variety of mechanisms, none of which appear at odds with the points outlined in "Crossing the Quality Chasm" [6].
Currently Victorian carer satisfaction surveys report high levels of satisfaction with palliative care services, though improving the accessibility and quality of palliative care services still requires a continued focus [7]. Maddocks and Rayner [8] state palliative care still has a long way to go, especially in improving services to indigenous and ethnic communities.
Support and the empowerment of patients and their carers throughout their cancer journey is emphasised by Victoria’s Cancer Plan [5]. Sustained efforts should be made to realise this goal for all Australians.
Though the future of health may be uncertain, whether in Australia or the U.S., improving quality, accessibility, and providing patient-centered care remain challenges for us all.
References
1. Finlay E, Casarett D. Making difficult discussions easier: using prognosis to facilitate transitions to hospice. CA Cancer J Clin. 2009;59:250-263.
2. Clayton JM, Hancock KM, Burtow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of life-limiting illness, and their caregivers. Med J Aust. 2007;186:S77, S79, S83-108.
3. Cancer survival and prevalence in Australia:cancers diagnosed from 1982 to 2004. Available at: http://www.aihw.gov.au/publications/index.cfm/title/10484. Accessed September 1, 2009.
4. Maddock I. Palliative care in the 21st Century, Med J Aust. 2003;179(6 Suppl):S4-S5.
5. Victoria’s Cancer Action Plan 2008-2011. Department of Health Victoria. Available at: http://www.health.vic.gov.au/cancer/docs/vcap/vcactionplan.pdf. Accessed September 1, 2009.
6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press; 2001.
7. Regional cancer centres needed to reduce ongoing inequity in cancer care outcomes. Available at: http://www.cosa.org.au/File/publications/22AUG08-cancersurvivalreport-inequitiesforruralAustraliacontinue.pdf. Accessed September 1, 2009.
8. Maddocks I and Rayner RG. Issues in palliative care for Indigenous communities. Med J Aust. 2003;179(6 Suppl):S17-S19.
9. Yuen KJ, Behrndt MM, Jacklyn C, Mitchell GK. Palliative care at home: general practitioners working with palliative care teams. Med J Aust. 2003;179(6 Suppl):S38-S40.
10. National Primary Health Care Strategy. Available at: http://www.phaa.net.au/.../SubmissionPrimaryHealthCareStrategy.pdf. Accessed September 1, 2009.