Supportive care: not only for cancer

PROFESSOR Ian Olver has written persuasively of the importance of comprehensive supportive care as an accompaniment to the management of cancer. We should extend the supportive approach more widely as it has relevance to most areas of health care.

Olver notes that “advances” in cancer care are widely heralded while effective support is given little media attention, even though such support embraces a wide range of symptoms relief, addressing the discomforts of the disease itself, the immediate and long-term adverse effects of chemotherapy, and the psychological and spiritual consequences that accompany the threat of cancer.

He notes that new targeted approaches to therapy bring the potential for new side effects and toxicities that will call for careful monitoring.

In other specialties, there are familiar diseases and discomforts that are equally at risk of missing effective supportive care when the focus of clinical attention is on pathology, investigation and therapy.

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Of particular importance in our current context are the conditions that affect a high proportion of the ever-increasing numbers of elderly patients: the chronic diseases of diabetes, airways disease, cardiac failure and osteoarthritis (all often grouping together); the problems of dementia, mental illness and frailty; and the compassionate care for the dying.

Supportive care in this context calls for the same holistic approach to assessment and care that Olver encourages for cancer.

Few elderly people have only one medical condition, and the multiple effects of several coincident diseases need comprehensive whole-patient consideration, along with a patient-centred approach that asks “what matters most to you?” Sometimes, what the doctor perceives as the most immediate or most pressing problem will differ from the patient’s priority; they may be most concerned with avoiding a transfer to hospital or wishing to cease some of the many regular medications that cause distaste.

Olver suggests that the burden of cost to patients undertaking new targeted therapies for cancer can amount to “financial toxicity”, which is a major cause of distress to patients and their relatives.

Aged care presents its own cost dilemmas. As the numbers of Australia’s cohorts in the elderly decades steadily build – 80s, 90s, 100s (there seems to be no limit) – we need to ensure that the burden of their care does not reach levels that are unaffordable and “toxic”, either for individuals, families or the Australian taxpayers.

It is hospitalisation, public and private, that constitutes a major portion of aged care costs, and any measures that prevent unnecessary or inappropriate placement in acute hospitals will be encouraged.

Home care is preferred by the majority of our elderly, and it is cheaper than any institutional placement.

This strategy will require families to maintain placement of an elderly member at home through undertaking daily care themselves, or through funding whatever carer supports are required.

Governments are experimenting with packages to encourage that option; they need to be flexible and broad in scope, building confidence through readily accessible phone and technological support, providing practical training in nursing skills, sourcing useful equipment, and deploying nurse practitioners to fill the void left by the current reluctance of many family practitioners to undertake home visits.

More availability of medical skills will be needed to facilitate closer monitoring of the complex clinical needs increasingly encountered in residential aged care facilities (RACFs).

Due to the numbers and care requirements of our elderly, an onsite family practice is now being considered as an essential component of the aged care facility team. Then, when a crisis occurs, rather than seeing hospital transfer as the only available course of action to satisfy their “duty of care”, nursing staff will have access to immediate skilled assessment and opinion.

The skills of a multi-disciplinary team will readily extend from the RACF to those based at home in the local community, offering them use of the RACF’s facilities for regular clinical review and for healthy ageing (in both its physical and social dimensions).

This will lessen the fear of aged care placement, will enhance the reputation of the facility in the community, and will bring new levels of volunteer and charitable support.

Ian Maddocks, AM, is emeritus professor of Palliative and Supportive Services at Flinders University. He is an eminent palliative care specialist, recognised internationally for his work in palliative care, tropical and preventive medicine. He was Senior Australian of the Year in 2013.