A communications framework
A communications framework should be developed which encourages and supports input into case discussion from all relevant team members.
Communication issues for health professionals
The shift towards palliative care represents a crucial step for patients with advanced cancer and their treatment team. Health professionals may find it challenging to communicate and manage this transition. Introducing palliative care as part of the team approach early after the diagnosis of advanced disease can facilitate this transition. Progression of disease may be rapid or may occur over a number of years with a series of recurrences and remissions. Contingency planning and thinking ahead will help health professionals create opportunities to discuss with their patients potential issues that may arise during the patient’s disease. It is important to make clear to the patient that they will receive optimal care at all times and that this transition does not imply discontinuation of care or abandonment by their MDC team.
Guidelines about discussing disease progression recommend open and honest provision of relevant information. The patient and caregiver, where appropriate, should be told about changes to the cancer, treatment efficacy and prognosis, making sure enough time is provided to allow discussion of the implications of this information and the patient’s emotional response and support needs. Teams should be encouraged to undertake communication skills training in order to improve the way they relate to other team members, cancer patients and caregivers.
The exchange of knowledge and expertise between larger and smaller teams should be encouraged. This gives health professionals the opportunity to improve outcomes for patients and work towards a best-practice approach to treatment and care.
Attitudes and perceptions about care, including end-of-life (EOL) and communication issues, are important aspects beyond clinical educational activities for health professionals. Health professionals involved in the care of people with advanced disease are encouraged to develop professional skills and to participate in regular reflective practice to ensure they can provide optimal care for their patients.
Choosing how and when to raise EOL issues with terminally ill patients can be challenging for health professionals. Overall, it is better to err on the side of ensuring that prognosis and EOL issues are accessible topics for patients and their families. Health professionals need to be sensitive about the way that they raise the subject and first explore the patient’s understanding. When discussing EOL issues it is important for health professionals to balance hope and honesty.
Dealing with patients with advanced disease can be stressful for health professionals. This is especially so when managing patients with EOL issues. It is important for health professionals to draw on the expertise of members of the MDC team in dealing with complex clinical problems. Debriefing and opportunities to access support services should also be made available to all team members.
See also - Case study: discussing palliative care and end-of-life issues
‘Not for resuscitation’ orders
Issues relating to ‘not for resuscitation’ (NFR) orders should be discussed with the patient and, where appropriate their caregivers. Issues that may arise from these discussions should be thoroughly documented.
For an Indigenous patient, the person or people that a hospital might consult to discuss NFR orders may be different. Particular kinship relationships can identify those who have primary responsibility for making NFR decisions.
NFR decisions should include discussions about being admitted into intensive care units and emergency departments and discussion about when cardiopulmonary resuscitation (CPR) may not be appropriate. CPR decisions will involve consultation between the patient, family, and relevant health care professionals.