Palliative Care

James talks to Bridget Johnson about palliative care and helping people with a life-limiting illness to live their life as fully and comfortably as possible. This is done by identifying and treating symptoms that may be physical, emotional, spiritual, or social.

Summary Writer:  Emily Nash

Editor:  Bridget Johnson

Interviewee:  Bridget Johnson

About Bridget Johnson

Bridget Johnson is a Palliative Care physician who enjoys working in a teaching hospital and palliative care unit in Sydney. Bridget completed her Bachelor of Medicine in 2003 at the University of Newcastle and was a physician trainee at Royal Prince Alfred Hospital. She completed her advanced training in 2013 and since then has worked as a palliative care staff specialist.

Palliative Care

With Dr Bridget Johnson, Palliative Care Consultant in Sydney, New South Wales, Australia 

Introduction

Palliative care helps people with a life-limiting illness to live their life as fully and comfortably as possible, by identifying and treating symptoms, which may be physical, emotional, spiritual, or social.

Case

You are a junior doctor on the Geriatrics ward and asked to review a patient with a reduced level of consciousness. The patient is an 85-year-old man who was admitted 5 days ago from a nursing home following an extensive acute stroke. He has significant co-morbidities including ischaemic heart disease, atrial fibrillation, COPD and chronic renal failure. The nurse has been handed over that he has an Advanced Care Directive, but can’t find it in the notes.

  • The care of anyone who has a life-limiting illness, anywhere in their trajectory
  • Aims to ensure symptom control, dignity and the best quality of life possible
  • Addresses physical symptoms (current symptoms and pre-empting future symptoms), emotional symptoms and psycho-spiritual symptoms
  • Team-based approach involving a Palliative Care specialist, GPs, Palliative Care nurses, Allied health team (OTs, physiotherapists and social workers), chaplain services and bereavement services
  • Advanced Care Plan
    • Can be written formally or on a scrap of paper
    • Broad statements that one can write as to their future health wishes if they were to deteriorate (e.g. unable to communicate, unable feed oneself) and the point at which they would not want their life prolonged
  • Advanced Care Directive
    • Specifically outlines what you would and wouldn’t want e.g. ventilator, CPR, ICU, IV fluids
    • Gives a voice to patients when they are incapacitated
  • Increasingly in nursing homes, it is becoming mandatory for residents to have an Advanced Care Plan and Directive drawn up so that in the case of them becoming incapacitated, people are able to fulfil their wishes
  • Patients are advised it is important to discuss their wishes with their family and their GP
  • Try to obtain a copy of this patient’s Advanced Care Directive
    • Speak to the family, GP and nursing home
    • Has the patient uploaded it to the MyHealth website?
    • Is there an electronic copy in the medical record?
    • Is there a photocopy in their old medical notes?
  • Full examination
    • Vital signs and GCS
    • Neurological examination
    • Cardiorespiratory examination
  • Review the notes
    • Determine severity of stroke and treatments given e.g. thrombolysis
    • Assess severity of co-morbidities
    • Investigations this admission
    • Determine if any new medical problems e.g. acute on chronic renal failure
  • Discuss current situation with Enduring Guardian
  • Goals of care can be curative, palliative or terminal and should be determined by:
    • Clinical situation
    • Prognosis
    • Patient’s preferences/Advanced Care directives
  • Enduring Guardian is a term used in NSW (varies between jurisdictions)
  • You can appoint an Enduring Guardian to make medical decisions, instead of your Next of Kin, e.g. if your child is in a better position to make decisions compared to your partner
  • Once this is documented, this person becomes your surrogate decision maker
  • Palliative Care consult directed by your Consultant or Registrar
  • If family or medical team are reluctant for Palliative Care to get involved, the junior doctor is able to advocate for and explain the importance of involving the Palliative Care team
  • If the family misunderstands the role of the Palliative Care team:
    • Explain the management of symptom control, role in supporting families, etc
    • Elicit whether the family have any particular concerns which could be addressed
  • If the medical team is reluctant to involve the Palliative Care team:
    • If the patient isn’t dying comfortably, or family don’t appear to be supported, and you think Palliative Care can help, the junior doctor can suggest to their registrar or consultant “Do you think it would be a good idea to get the Palliative Care team involved?”
  • Important to tell family that Palliative Care team will be visiting
  • Palliative Care team are always happy to be involved, especially in cases of difficult family dynamics or complex co-morbidities
  • Check their understanding of the Palliative Care team
  • Explain the role of the Palliative Care team
    • Manage symptoms and be pro-active about symptoms that might arise e.g. ensure medications are appropriate given chronic renal failure
    • Provide emotional support for families including bereavement support
    • Discuss where death might take place and facilitate death indesired location (at home, nursing home, palliative care unit or in hospital)
  • Direct them to resources on the Palliative Care Australia website, or print off a pdf brochure if they don’t have internet access
  • Be comfortable with letting families ask questions
  • If unsure, just say you are unsure, and that you will find an answer e.g. organise a time for the registrar to phone them the following day
  • Identify when you find a situation emotionally confronting, and raise this with your registrar or consultant, so that your team can look out for you
  • De-brief with other colleagues, family and friends
  • Seek external help if needed e.g. Employee Assistance Program provides free counselling
  • Remember that strong doctors demonstrate insight and seek help when needed
  • Listen to the recent podcast “Self Care” with A/Prof Amanda Walker for more tips
  • Don’t underestimate the difference you can make as a junior doctor, by advocating for dying patients to havea dignified and comfortable death
  • Give patients and their families space and sensitivity around palliative care, allow them to ask questions and facilitate them obtaining answers from yourself, the registrar or consultant
  • Take care of yourself and put up your hand if you need help

Related Blogs

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Tags: #advanced care directive,#advanced care plan,#bereavement,#comfort,#de-brief,#death,#dignity,#enduring guardian,#multidisciplinary team,#next of kin,#nursing home,#palliative care,#patient advocacy,#prognosis,#self care,#symptom control

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2 Comments

  1. Tamar

    April 18, 2017 at 8:58 pm

    Dr Johnson, living your dream. I am so proud of you and all the fantastic work you do. Much love from an old friend from halfway round the world.

    Reply

  2. Demi Naylor

    November 13, 2017 at 7:38 am

    I’m ao proud of you and everything you’ve done! It seems a lifetime ago that you gave yourself just one morning tea and lunch time a week off studying so you could follow this dream!

    Reply

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