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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.
- Related: MJA — The importance of supportive care for patients with cancer
- Related: MJA InSight — Ian Maddocks: A new old age
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.
Thankyou for the comments from general practice. I agree that insufficient support is available to encourage family members to undertake care in the patient’s home. Usually, a daughter (occasionally a son) has to take leave from work. There could be short-term salary assistance for this period. Private funds have not taken seriously the opportunity to save expenditure by encouraging care at home – it needs flexible options. .There is no question that the GP workforce copes with most Palliative Care, and usually does it well. Rural areas have the disadvantage of less access to specialist Palliative Care services, but the great advantage of knowing the patient and having ready access to a local hospital bed and the local residential care facilities.
Families have insufficient support to undertake home care; short-term salary assistance would assist. Private funds provide little for care at home. GPs cope with most Palliative Care, and do it well. Rural areas have less access to specialist Palliatie Care services, but know the patient and can use local local hospital and aged carecare facilities.
Inadequate expertise in RACFs supports basing a family medical practice in the RACF to skill all staff, link with community care and encourage community support.
Referrinig to A&E an old person with multiple disease who wishes to avoid hospital needs a ‘duty of care’ on site. To manage dying in such circumstances, if done with family support compassion and skill, can be best practice.
In this past week, I have cared for two people who came to ED from home with end-stage chronic respiratory disease, using continuous home oxygen. Both were cogitively intact and lived alone, with no carers (though they both had home service packages). These people are very fragile – small set-backs can precipitate acute exacerbations. They don’t want residential Aged Care, and were both cognitively competent.
Neither of these people had end-of-life plans. I agree with Rural GP that people who become acutely sick need acute care – UNLESS they have end-of-life plans AND the resources to manage. IN the absence of 24 hour care, however, how can this be provided at home?
ALthough many people express the desire to die at home, many families don’t have either the skills or the confidence to manage when the end actually comes. If EDs help to fulfill an important service at the end-of-life, and can manage discomfort and anxiety without invasive medical care, a very important service need is being fulfilled. An ED presentation in these circumstances is not a “failure” of care, but a fulfillment of care.
As a GP I have to concede that referrals to A+E from RACF’s or home visits are a big problem and we are letting our patients down.
GP’s know what the problems are. Elderly patients with multiple chronic illnesses get acutely ill more often. Inadequate nursing support at RACF’s, families/ spouses unable to provide the carer role and lack of funding for GP’s to provide this level of care.
The model described relies on nurses working using algorithm’s and flow charts, liaising with a distant doctor. It is clunky, risky, hell bent on diverting patients from A+E, and does not cover after hours.
The author seems either dismisses or does not know what General Practice is really doing out there. We manage the bulk of dementia and palliative care and chronic disease. We invented holistic care.
Out in the community, we are seeing more acutely ill elderly patients and packages and home care will make little difference. People require admission when they acutely sick, no matter how we try divert them. They need their delirium/ falls/Shortness of breath managed now.
What you need is a GP with his practice team who knows the patient. Now if you pay GP’s enough to provide IV services , and have quick access to radiology and pathology and fund us to undertake administrative work , then we have useable model. Currently ,the system fails us, and the patient. We spend so much time on the phone, negotiating beds, ACAT referrals and liaising with family.
I wonder if the author feels that GP’s are the “charitable and volunteer support” to prop up the new model.
” 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”
There is no doubt that home care is the most preferred option, however reference to ” families” des not appreciate the stress that ” families” are under and that ” families can be as small as one other person. Moreover given the longer generations and older mothers, care giving is usually up to one female member who may be part of the sandwich generation with young children and older ailing parents or parents in laws and may be working at the same time
Moreover there are extremly limited care packages available at Level 2 and almost none available at Level 3 and 4 and private care can be up to $60 an hour or more.