INTRODUCTION AND OVERVIEW

In the mind of the general public, palliative care is commonly equated with terminal care, and many members of the medical community no doubt share this opinion. Traditionally, palliative care has predominantly provided service to cancer patients and their families. However, the role of palliative care is much richer and more varied than this. Palliative care principles can readily be applied to many incurable diseases as they become more severe, and can also be useful in the management of symptoms during the earlier stages of disease.

Palliative care, at its best, is provided by a team of individuals working towards common goals for a particular patient. The team may include doctors, nurses, allied healthcare staff, counsellors and family members. Symptom control, achievement of optimal quality of life and assistance with decision-making are all components of palliative care that can be provided by the general practitioner (GP). The critical role of the GP in the coordination of patient care is particularly pronounced for patients with advanced disease. Furthermore, a GP who has known a patient for much of their life is likely to have worthwhile insight into their values and wishes, and is well placed to assist them in negotiating difficult transitions.

GOALS OF CARE

It is often helpful to establish and focus upon the goals of care for a patient. These will be influenced by the nature and stage of the disease, the age of the patient, their general health and their life philosophy. As cancer progresses, the situation may become more complex and decisions may seem increasingly difficult. It is helpful at these times to return the focus to the goals of care and reflect on the outcome that we are trying to achieve. This will assist in more clearly identifying a pathway that is likely to accomplish these objectives. The GP should take an active role in reviewing the overall situation and incorporating a holistic understanding of their patient.

For example, a 55-year-old woman first confronted with a diagnosis of breast cancer is likely to elect to pursue chemotherapy if this is advised. She will consider the temporary side effects, reduction in quality of life and time taken to attend therapy to be worthwhile in view of the potential benefits. An 83-year-old woman with multiple other medical issues resulting in some frailty will often be more susceptible to adverse effects of routine chemotherapy for breast cancer. She may find the effort required to attend clinics, undergo invasive investigations or procedures and the time taken to recover from each cycle of chemotherapy to be an unacceptable trade-off for the potential benefits, which in all probability will be of a lesser magnitude.

Many important decisions may need to be made by a person confronted with a life-limiting illness. For an excellent and practical guideline on how to approach this, the reader is referred to Clayton & Hancock, ‘Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a terminal illness, and their caregivers’, published as a supplement in the Medical Journal of Australia.¹

CARING FOR THE WHOLE PERSON

Nowhere is integrated and holistic care more important than when dealing with death and dying. Obviously the physical aspects of care need to be attended to, and dealing with various symptoms will be dealt with in detail in this chapter. Obvious also is the impact of emotional, social and spiritual/existential aspects involved in confronting end-of-life issues.

A deep-seated fear of dying, for example, or longstanding and unresolved guilt can have an enormous impact on how a patient deals with physical pain. It is not uncommon for deeper emotional and existential issues to influence and magnify such symptoms. If physical treatments only are administered (e.g. prescribing escalating doses of pain killers) but the underlying emotional and existential issues are not acknowledged or dealt with, then the problem of pain will likely be unsolvable, whereas if these deeper issues are dealt with well, the pain will often be far more manageable.

Most patients confronting life-threatening illnesses wish to speak to their medical team about spiritual and religious issues (see Ch 12, Spirituality). Whether the doctor provides such counselling or helps to link the patient with counsellors, pastoral care and allied healthcare professionals, one way or another this aspect of care needs to take place and not be ignored among the more obvious and apparently more pressing physical needs.

At all times one needs to also bear in mind that it is the whole family who will be experiencing the grief and anxiety associated with the illness—sometimes far more grief and anxiety that the patient, who may already have come to terms with their situation.

THE ROLE OF COMPLEMENTARY THERAPIES

The frequency of complementary therapy use by cancer patients may be as high as 83%² (see Ch 24, Cancer). This includes herbal medicines, music therapy and physical therapies such as acupuncture, among others. Patients use these therapies to improve symptoms, in the hope of curing cancer or increasing survival, and as a response to pressure from family or friends.³ It is certainly reasonable to encourage the use of those therapies that are proving helpful to the patient without causing undue hardship or interfering with conventional treatment. Some incur a considerable cost with little or no benefit, and occasionally there may be a risk of the therapy interfering with conventional medical care or causing harm to the patient. For example, many herbs can interact with drugs such as warfarin. The GP has an important role in discussing the use of such therapies with the patient.

PAIN

Pain is a complex experience involving specific neural pathways that convey nociceptive information to consciousness. Neuronal systems also exist that modify pain—for example, descending inhibitory pathways in the central nervous system. This chapter focuses mainly on cancer pain, but many of the principles can be applied to non-malignant pain in patients with advanced or near end-stage disease. Chronic pain, while sharing some features, requires important differences in approach and is not discussed here (see Ch 38, Pain management).

Pain is common is cancer and more so in advanced malignancy, with 70–90% of patients reporting pain.⁴ It is also common in the elderly (28–86% of nursing home residents⁵) and in those with other chronic disease (e.g. 40% of patients with Parkinson’s disease). As such, competent assessment and management of pain is a crucial skill for GPs.

The most effective approach to cancer pain requires consideration of the pathophysiology as well as the aetiology of the pain.