A palliative approach can support quality of life for older people at the end-of-life. 'The Surprise Question' can help identify those needing a palliative approach and the 3 key processes help deliver the palliative approach.
The Surprise Question
The palliative approach is not just about the last days or weeks of life. 'The Surprise Question' is often used to help identify people for whom a palliative approach would inform the quality of their care and their quality of life. Ask yourself:
'Would I be surprised if this person died in the next 6 to 12 months?'
If you would not be surprised if the person died, a palliative approach should be considered.
Three Key Care Processes
Everybody needs to talk about and plan for what they would like to happen at the end of their life. The first of the three processes looks at this planning, called Advance Care Planning (or ACP). ACP helps guide decision-making when the person can no longer communicate their wishes. Although this is the first process, if not completed, it can be undertaken at any stage.
The National Framework for Advance Care Directives describes ACP as:
'...a process of planning for future health and personal care whereby the person’s values, beliefs and preferences are made known so these can guide decision-making at a future time when that person cannot make or communicate his or her decisions'.
Key aspects of ACP:
- Identifying the patient’s wishes and preferences for future care.
- Conducting discussions when a patient or resident is still relatively well.
- Reviewing the ACP regularly to identify if preferences have changed or if there are other things that need to be considered.
- Documenting care decisions that have been discussed.
More information can be found in
Advance Care Planning section.
When it is likely that death could occur in the coming months, the second care process, a palliative care case conference should be undertaken.
A palliative care case conference can help review and clarify goals of care and treatment plans as the older person’s anticipated death gets nearer
Key aspects of palliative care case conferences:
- Indicates and creates acceptance that the person may be in the last months of life.
- Alert clinicians to review the older person’s condition, their care needs and future care plan.
- Incorporates broader assessment which integrates comorbidities, physical, emotional, psychological and social factors.
- Provides discussion about choices to be made in the event of a sudden decline or deterioration.
- Facilitates the ability to act on preferred choices through discussions with the older person and/or their substitute decision maker.
- Identifies the role of comfort care as well as its value when death is closer.
- Addresses common clinical symptoms: pain, shortness of breath, nutrition and hydration issues, delirium and oral care.
- Provides a shared care plan to be reviewed on a monthly basis.
More information can be found in the
Palliative Care Case Conference section.
In the last days of life a planned approach to care is important.
Terminal care planning should lead to a structured multidisciplinary care plan which details the essential steps for the care of the dying person. It should address any specific clinical problems the person has or is likely to encounter. This will help ensure care that is focused on the individual’s needs.
Key aspects of terminal care planning:
- Care decisions are reviewed frequently.
- Goals of care focus on the older person’s physical, emotional and spiritual comfort as well as support for the older person’s family even though it is not possible to be prescriptive about when death may occur.
- Recognition of the following signs and symptoms. Three or more of the following signs suggest that terminal care planning needs to be considered:
- Rapid day-to-day deterioration that is not reversible.
- Requiring more frequent interventions.
- Becoming semi-conscious with lapses into unconsciousness.
- Increasing loss of ability to swallow.
- Refusing or unable to take food, fluids or oral medications.
- An acute event has occurred requiring revision of treatment goals.
- Profound weakness.
- Changes in breathing patterns.
Remember the decision to start terminal care is a team decision that takes into account all the relevant clinical information. Discussions with the person and their family about the change in care focus are critical.
More information can be found in the
Terminal Care Planning section.