Consultant physicians working with patients - Royal College of ...

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2 Specialties Palliative medicinePalliative medicineDr Bee Wee MBBCh MRCGP FRCP PhD Consultant and senior clinical lecturer inpalliative medicineDr Stephanie Gomm MBChB FRCP MD Consultant palliative medicine1 Description of the specialtyPalliative medicine, recognised in the UK as a medicalspecialty in 1987, is defined as ‘the study of patientswith active, progressive, far-advanced disease, for whomthe prognosis is limited and the focus of care is thequality of life’. Palliative physicians work withinspecialist palliative care teams, assessing and treatingpatients with difficult symptoms and complexpsychosocial and spiritual problems. The specialistsociety for palliative medicine physicians in the UK isthe Association for Palliative Medicine of Great Britainand Ireland (APM) (www.apmonline.org).Traditionally, most patients referred for palliative carehave advanced cancer. 1 More patients with end-stageprogressive non-malignant diseases are now beingreferred to specialist palliative care, from 13.6% in2006–7 2 to 17% in 2010–11. 1 Since 2000, the moststriking increases are in outpatients (8% to 24%),hospital support (6% to 20%) and day therapy (5% to17%). For specialist palliative care inpatient units, theproportion of patients with a diagnosis other thancancer has increased from 3% to 11%, and the lowestincrease is for community settings from 4% to 10%.Inequity of access to specialist palliative care bydiagnosis, geography, age and ethnicity remains.2 Organisation of the service and patternsof referralA typical serviceSpecialist palliative care services include some or all ofthe components shown in Table 1. These are delivered bymultiprofessional teams who may come from differentorganisations within the National Health Service(NHS) or voluntary sector. These services are usuallypart of supportive and palliative care networks (withincancer networks) and/or end-of-life care networks.Arrangements vary to reflect local structures andneeds. Relationships between palliative care networksand cardiac and renal networks are developing.Table 1 Components of specialist palliative careservicesClinicalInpatient specialistpalliative careCommunity palliative careteamsHospital palliative careteamsDay therapy servicesOutpatient clinicsAcademicEducation and trainingprogrammes/centresResearch groups anddepartmentsSources of referralIn 2007–8, 3 referrals to specialist palliative care camefrom: GPs or district nurses (28%) hospital doctors (34%) other specialist palliative care teams (16%).Patients are referred when specialist palliative careexpertise is needed in: symptom management management of complex psychosocial and spiritualissues terminal care decision making in uncertain progressive situations.Sometimes one-off consultations are required. Moreoften, ongoing shared care is helpful. Referrals may betriggered by patients, families or other professionals.3 Working with patients: patient-centredcareA patient-centred focus is fundamental to palliative carepractice: helping patients to express their wishes andachieve their preferences in relation to symptommanagement and end-of-life care, within amulticultural context.C○ Royal College of Physicians 2013 189
Consultant physicians working with patientsNational strategies to promote patient-centredcare for end-of-life care include: Endoflifecarestrategy(England), 4 Living and dying well (Scotland), 5 thepalliative and end of life care strategy (Northern Ireland) 6and implementation of the Sugar Report (Wales). 7Resources for patient/carer education and supportinclude: Help the Hospices (www.hospiceinformation.info) The National Council for Palliative Care (NCPC)(www.ncpc.org.uk) Macmillan Cancer Support(www.macmillan.org.uk) Maggie’s Cancer Caring Centres(www.maggiescentres.org) National End of Life Care Programme(www.endoflifecareforadults.nhs.uk) healthtalkonline (www.healthtalkonline.org).User involvement occurs at local and regional levels.Electronic palliative care coordinating systems(EPaCCS) have been piloted in England and are nowbeing implemented across the country with a nationallyapproved standard (Information Standard Board) for itscore content. 8 Dying Matters, a national coalition inEngland, is promoting public awareness of dying, deathand bereavement (www.dyingmatters.org). Patients andcarers are becoming more involved in education,research and service evaluation.4 Interspecialty and interdisciplinary liaisonMultiprofessional specialist palliative care teamsIntegrated and flexible teamworking across professionalboundaries is essential. See section 6 for the role ofconsultants in palliative medicine. Other essential teammembers include: clinical nurse specialists: provide assessment,support, monitoring, care planning andcoordination, bereavement support and training fornon-specialist staff specialist physiotherapists/occupational therapists:provide rehabilitation of patients with disabilityfrom advanced disease and facilitate rapid safedischarge home for patients; increasingly importantas advances in treatment alter the natural trajectoryof incurable diseases specialist social workers: provide advice on financialissues; organise domiciliary/residential social care;provide psychological and bereavement support topatients and families, including children.Other team members include specialist pharmacists,dietitians, chaplains, clinical psychologists, counsellors,and creative and complementary therapists.Working with other specialtiesClose cooperation between specialists in palliative careand those in other disciplines, especially oncology,surgery, gerontology, cardiology, renal medicine,respiratory medicine, mental health, radiology andorthopaedics, is mandatory. Specialist palliative careteams are small, so it is rarely possible for these teams toprovide comprehensive consultant input to allmultidisciplinary teams (MDTs) in acute hospitals.Consultants in palliative medicine rely on good workingrelationships and communication with colleagues inother disciplines.Working with GPs and GPs with a special interestGPs provide palliative care within the community. Mostcommunity palliative care teams are advisory. Localarrangements vary. In some areas GPs with a specialinterest (GPwSIs) have been appointed to facilitatepalliative care training for local GPs. Many specialistpalliative care units employ GPs as specialty doctors orhave trainees drawn from GP specialty training schemes.This helps to develop expertise within primary care andraises the standard of primary palliative care locally.Other specialty activity beyond local servicesPalliative medicine consultants provide strategicleadership for palliative and end-of-life care within theircancer networks, strategic health authorities and healthboards or trusts, promoting quality and equity of accessfor cancer and long-term conditions and developingguidelines, audit and outcome measures.5 Delivering a high-quality serviceWhat is a high-quality service?High-quality specialist palliative care services have thefollowing characteristics: 24-hour access clear referral and discharge criteria based on neednot diagnosis:– ability to receive referrals rapidly and securely, egby fax/email– clear process for clinical screening of referrals190 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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