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Small change for big effect

Annabel McGilvray
Med J Aust
Published online: 19 May 2014

It is one of Australia’s youngest and smallest specialties but palliative medicine is rapidly establishing itself as essential for patient-centred end-of-life care

Whether it is adjusting medication to allow a patient to eat again, or relieving severe pain to allow quality time with family and friends, minor changes often make a large impact on patients’ lives in the context of terminal illness.

“I look at my radiation and medical oncology colleagues with patients who are symptomatically very unwell from the treatments that they are being given, and yet I can come in and give people medication to make their mouth ulcers better or make their mouth feel better and suddenly they can eat again”, Dr Caitlin Sheehan, a palliative medicine staff specialist at Calvary Health, says.

“There’s a lot of quality of life that comes just from that.

“Making little differences to patients, giving them medications that can fix their pain or take away their nausea and vomiting, can make a big impact on their lives.”

Palliative medicine is one of Australia’s youngest and smallest specialties, first recognised as a specialty eligible for Medicare funding in 2005, and the Royal Australasian College of Physicians’ Australasian Chapter of Palliative Medicine (AChPM) still has just over 300 Fellows.

But there is growing interest in the benefits of increased palliative care, both from within the profession as well as from governments and the community sector.

Recent US research has shown that integrating palliative care into management soon after diagnosis with a life-limiting disease, such as lung cancer, can improve patients’ quality of life and mental health, can lead to less inappropriately aggressive end-of-life treatment, and even allow longer survival.

Critically, it also results in less cost to the health system compared with conventional “prevent death at all costs” approach. It’s a win-win intervention.

All this gains greater significance in the face of Australia’s ageing population and analyses of the high cost of treatment in the final years, months and weeks of life.

“Death is considered a failure by other medical professionals. It’s terrible for a patient to deteriorate and to die”, Dr Sheehan says.

“We’re stepping back from that and looking at all these life-prolonging measures that we’re using across the board and saying, ‘Hang on a second, maybe there’s a better way to do things’. We’re looking more at patients’ quality of life.”

In doing so, Dr Sheehan and her palliative medicine specialist colleagues are establishing Australia as a leader in research and policy in palliative care, with a focus on training, communication and collaboration.

Training

Unusually, there are multiple entry points to palliative medicine in Australia.

Shortly after the establishment of the AChPM in 1999, an innovative dual training pathway was set up to enable those already trained in other clinical specialties to qualify via a 3-year advanced program.

Alternatively, doctors can enter the specialty by completing the basic physician training followed by the advanced training program.

President of the Australia and New Zealand Society of Palliative Medicine, Dr Mark Boughey, says that many doctors now transfer to palliative medicine from generalist fields such as general practice and geriatrics.

“They seem to be the two areas that transition across to do advanced training in palliative medicine.”

The fact that general practice training can be shorter than basic physician training also makes it an attractive pathway for many junior doctors.

Alongside standard palliative medicine training, there is separate training for the subspecialty paediatric palliative medicine, which is also part of the Chapter.

A fourth alternative entry pathway is through the palliative medicine diploma, a six-month clinical placement option that doesn’t give specialist status but demonstrates additional interest and ability in the area.

With increasing awareness of the benefits of palliative care, there has recently been great interest in the diploma, with 80 awarded in 2011 alone.

Demand is increasing

Australian Institute of Health and Welfare figures show that the number of palliative care-related hospital admissions rose by nearly 50 per cent in the first decade of the 21st century.

Looking ahead, Health Workforce Australia’s recent Health Workforce 2025 report forecasts that population ageing together with a trend towards earlier referral is likely to continue increasing demand for palliative care specialists’ services.

This, it says, could lead to workforce shortages over the coming decade.

Some states and territories have recognised the potential workforce issues and have made moves to provide funds to increase the number of training placements and to administer training programs.

To date, the Victorian Government has been the most generous contributor, facilitating the establishment of a formal training program run through the Centre for Palliative Care, affiliated with St Vincent’s Hospital Melbourne.

Dr Amy Birtwistle is in her final 18 months of advanced training in New South Wales after completing the basic physician’s exams.

She says that the ethos of palliative care is very holistic — a genuinely patient-centred approach to medicine.

“A lot of the time we talk about a holistic approach in medicine — a total-person care approach — not just fully focusing on the science of the disease, but most of the time it’s not done.

“In palliative care it really does feel holistic. It’s not just about disease and the mechanics of what they’re dying from. It’s about who they are as a person and what’s important to them and what their priorities are, what their family and social set-up is.

“It really is looking at everything about the person rather than just focusing on the disease process.”

Talking the talk

In that context, when it comes to palliative medicine in practice, symptom relief is important but the best skill a specialist can have is good communication skills, says Dr Boughey.

“Surgeons use a scalpel; a palliative medicine specialist’s scalpel is their communication skills.”

There’s vital discussion with patients, friends and families, alongside ongoing communication with fellow health care workers in interdisciplinary palliative care teams as well as other specialists.

“You do have to have a genuine interest in communication and see that as part of practice”, Dr Boughey says.

“And you do have to have a fairly strong sense of who you are and understand where your core being is because you’re so challenged day-to-day by other people’s issues.”

Such challenges contribute to the need for support in the face of what can be a very emotional and stressful environment, says Dr Sheehan.

“This is highly emotional and potentially fairly stressful work but I think there’s great awareness among palliative care physicians and palliative care staff members anywhere that that’s true”, she says.

“I think there’s a care among our colleagues that’s perhaps more focused.

“Certainly, looking after each other within the specialty is something that I come across more often than in other specialties.”

She adds that a good sense of humour can be very important in terms of resilience.

The future

Both Dr Boughey and Dr Sheehan are actively involved in the increasing amount of research occurring in the field.

The relative youth of the specialty makes it an exciting time for research with lots of potentially groundbreaking investigation to be done.

“The studies that are being conducted in Australia — some of the collaborative studies — are among the largest studies in any specialty of particularly very common symptoms”, Dr Sheehan says, referring to the Palliative Care Clinical Studies Collaborative (PaCCSC) multisite investigations being coordinated out of Flinders University in Adelaide, South Australia.

Thanks to new research and policy developments, there is also increasing diversification within palliative care.

This includes moves to increase treatment of non-malignant life-limiting illnesses such as neurodegenerative diseases and organ failures, in addition to malignant diseases such as cancer where palliative care has long played an important role.

It means today’s specialists are working in hospitals, community settings, hospices and private clinics. Sometimes it is all of them together.

Dr Boughey has now been involved in Australian palliative medicine for 25 years, since shortly after it was first recognised as an academic discipline in the mid 1980s.

He was one of the first palliative medicine registrars at the Peter MacCallum Cancer Centre in Melbourne and is now involved in supervising about 35 Victorian trainees in the AChPM program each year. This is in addition to promoting the benefits of palliative care in less developed countries.

Dr Boughey says that ultimately it’s about helping people at a crucial part of their lives.

“There’s a genuine humanistic, person-to-person response. If you can help create a great care around dying, it really has huge repercussions for family and people beyond palliative care.

“You do see that a small difference — having a patient-centred approach, listening to their problems genuinely and responding to them — can make a significant change.”

One of the “fathers of palliative care”, Canadian Dr Frank Ferris, once said that palliative care would change the world. Dr Boughey says Australia’s new specialists are doing their bit.

“Often I think that in a small way, what we’re doing in palliative care is actually starting to reshape health care — around building communication skills training not just into medicine and general practice, but into surgical training and all the other specialty training areas.”

  • Annabel McGilvray


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