Palliative Medicicine Staff Specialist, Calvary Health Care Kogarah
Cairns was the host city for the 2015 Royal Australasian College of Congress ‘Breaking Boundaries and Creating Connections’, an opportunity to delay winter while inspiring and expanding the mind.
Plenaries addressed a wide range of topics, including refugee and asylum seeker health, origins of clinical governance, medicine in Madagascar, the conundrum of consumer driven care, the persistent disparity in health care between first peoples and non-indigenous populations, and contrasting the depths and peaks of modern medicine, challenging us to provide excellent and compassionate care. Updates were offered on wide ranging topics such as Ebola, sleep, amyloidosis, genetics, integrated care, gender dysphoria, and faecal microbiota transplantation.
This report summarises presentations at the Congress on ‘end of life care’.
There were opportunities to meet physicians and trainees from both sides of the Tasman, students through to retiring physicians, to break barriers to the conversations about palliative care and the inevitability of end of life, encouraging collaborative care, respecting and responding to community expectations, and accepting the limitations of resources. There was a sense that while the science and politics of health are clamouring for attention, the art of medicine persists.
Intensive care unit physician, A/Prof William Sylvester, discussed advanced care planning, from Hippocrates with beneficence and nonmaleficience, to modern goals of respecting autonomy, informed consent, dignity and prevention of suffering. Conversations about acceptable outcomes for quality of life are easier to broach, more useful than specifics of care, and can be aligned with treatment options and prognosis. Establishing and documenting surrogate decision makers is important. A randomised controlled trial on advanced care planning was statistically significant for knowing end of life care wishes, patients and families being more satisfied with end of life care, and reduction in stress, anxiety and depression in families at three months. This empowers patients now, not just in the future, can be used in patients with dementia and aligns with religious and ethical principles.
The managing end of life support panel discussion addressed aspects such as: who cares for the dying; when to refer to palliative care; need for training in all specialties; ATSI and CALD cultural competency needs a team approach; cannabis for symptom relief; terminal sedation and voluntary palliated starvation indicating clinician’s helplessness vs patient suffering; and disability does not imply distress or a wish for death. The goal is to relieve suffering and regain dignity.
Dr Frank Brennan, palliative care physician pivotal in establishing renal supportive care at St George Hospital Kogarah, outlined many barriers to and myths about palliative care. The definition of palliative care (WHO 2002) addresses care in life-threatening illness, not only cancer. Palliative care principles can be applied across many disciplines, e.g. end stage organ failure and motor neurone disease, extending experience gained from care of cancer patients. Balancing with acute management, often essential to good symptom control, is complex. Recognising when diseases are life-limiting allows end of life discussions and appropriate care. Limited palliative care resources and uncertain prognostication in non-malignant disease trajectories necessitate a combined approach. Palliative care provides a real alternative to active management.
Other sessions expanded on advanced planning, the rights of the child at end of life, the parents’ role in decision making and compassionate medicinal cannabis in Canada.