Early Palliative Care
From Susan Buckingham
This short video explains the rationale, the reason for early palliative care. It describes the three different typical patterns or trajectories of physical decline that most people have at the end of life, each with other typical dimensions of need.
Palliative care improves life’s quality and in some cases may even prolong life. It offers an alternative to treatments of low benefit and promotes “realistic medicine”. Patients, families and clinicians can all benefit from considering early palliative carefully integrated with on-going care to meet the likely needs of people with advanced illnesses.
So what does early palliative care look like for people with different conditions? There are three main patterns of physical decline as people’s health deteriorates in the last phase of life
a relatively rapid decline, typically of progressive cancer
an intermittent decline, typically organ failure and multi-morbidity
a gradual decline, typically of frailty or dementia
But research studies have confirmed that dying like living is a 4-dimensional experience: physical; psychological; social and spiritual. So let’s consider these 4 dimensions for people with each of these three patterns of physical decline.
Let’s consider the rapid trajectory first. Physical decline may occur quite quickly after a relatively stable period. The social dimension tends track the person’s physical decline However psychological distress and anxiety tend to be worse at four times in the cancer journey - around diagnosis, after treatment ends, at recurrence and around death, similar times to when existential issues may be expected.
So people on this trajectory can benefit from aspects of early palliative care even when they may still be physically well; other dimensions such as anxiety can cause major distress early on– so addressing anxiety and other symptoms and family stress from first presentation is really helpful.
So in the intermittent trajectory of organ failure and multi-morbidity – what’s happening here? Well the physical trajectory has these episodic dips, usually followed by partial recovery- but death can occur during one of these episodes of deterioration or in between them. Social contacts reduce and psychological distress often occurs at these same points. Spiritual problems are harder to predict, - these may be moderated by good relationships and support.
So for people with progressive heart, lung, liver or kidney failure – early interventions that address and reduce psychological or family problems may be more effective than just focussing on the physical health and treatment plan. And similarity, when managing the acute episodes, we should consider all the dimensions of need.
The gradually declining health trajectory, let’s look at that one now, typically found in people with frailty. A gradual decline in physical health may happen over many months or years. For people with dementia this is accompanied by increasingly impaired cognitive function. Looking at the social dimension and the psychological decline and even existential distress, these often dip considerably before the end of life: depression or family or social isolation or loss of meaning may predate a final physical illness.
The message here is to support people in these other dimensions, not just the physical one and promote resilience by enabling people to do as much as they can, by discussing and addressing common anxieties and fears such as loss of independence, dementia or being a burden which are more distressing than dying.
So the plan to help everyone live as well as possible until the end of life by offering early palliative care is
identify people early (if appropriate from diagnosis) and introduce early, integrated palliative care
consider people’s different dimensions of need at present, and discuss what matters most to them
discuss what often happens in the different illness journeys with patients and their carers so they know when they might need more help and help them cope in their own ways
While acknowledging the uncertainty, make an individual anticipatory care plan with patients and families, and document and communicate and review this regularity with everyone who needs to know.
Identify early, assess all dimensions, and plan for all predictable eventualities. Remember; identify, assess, talk and plan, and communicate with all involved.