GPs often have established relationships with the patient and family. This means they are well placed to understand their medical history and needs as well as their individual circumstances. In many cases, GPs may have been involved in providing ongoing care for chronic diseases.

As a GP you may be providing palliative care directly or you may be working collaboratively with a specialist palliative care team. The CareSearch GP Hub outlines core professional activities including communication, assessing and responding to symptoms and needs, planning care including ACP discussions, dealing with deterioration and emergencies, caring for the dying patient, and supporting bereavement.

HealthPathways SA is an online portal that provides General Practitioners (GPs) and other health professionals easy access to comprehensive, evidence-based assessment, management and referral pathways for specific health conditions. SA Health Pathway holds detailed information relating to palliative care and care of older people.

People living with dementia who are in the last months of life require ongoing assessment as to their needs. They may experience declining mobility, pain, and sleep issues as well as problems with eating, breathlessness, depression, and anxiety. Delirium also needs to be considered. Family and aged care staff can be helpful in recognising changes in behaviours or routines that can signal changes. Consider if your patient would benefit from referral to a palliative care team.

The Advance Project has free Dementia Specific Training and Resources. The resources can make initiating end-of-life conversations and assessing palliative needs of people living with dementia easier, enabling better more person-centred care. The RACGP aged care clinical guide (Silver Book) addresses both palliative care and end-of-life care and dementia.

Family and friends are often essential in providing care and support in the home or aged care setting. Looking at how family and carers are connected to care processes and decision-making is helpful to all involved the person, the family and carers and the health team. You can:

• Acknowledge and include family carers as part of the care team
• Address advance care planning including preferred site of end of life care
• Respect cultural or religious considerations when planning care
• Encourage family carers to take care of themselves
• Provide carers with information about services and resources including financial supports
• Help them feel comfortable about accepting offers of support from family and friends
• Acknowledge grief, loss and bereavement

Paramedics regularly encounter patients living with a life-limiting illness. Some patients are already connected to specialist palliative care services, while others may not yet be connected but could benefit from a palliative approach to care. Paramedics respond to these patients when the GP or specialist palliative care team are unavailable. However, the emergency department may not be the most appropriate or desired place of care for people with a life-limiting illness, especially someone living with dementia. Paramedics are well placed to use their existing scope of practice, coupled with clinical back-up assistance where required, to provide effective palliative and end-of-life care to patients in the community. To ensure paramedics treat the person according to their wishes, accessing documented goals of care in a timely manner can be crucial. In South Australia, paramedics use a Resuscitation Plan 7 Step Pathway to understand patient wishes and act accordingly.

The PEPA Learning Guide for Paramedics outlines core aspects of palliative paramedicine, including the palliative approach to care; communication; providing palliative care; and death, dying and bereavement.

Palliative care can be accessed at home and managed by GPs and community nurses. People whose care needs exceed the capacity of their GP or community nurse should be referred for assessment by specialist palliative care.

Specialist palliative care teams work in a consultative role with general practitioners and other health care providers when patient’s needs cannot be met exclusively by primary care teams. The primary goals of patient care are to control symptoms, maximise function, maintain quality of life and provide comfort. A person is eligible for referral to specialist palliative care services for assessment if:

• They have a progressive, life limiting illness, and
• They or their decision maker, is aware of, understands and has agreed to a palliative care referral.

Referrals can be made by medical practitioners, other health professionals and the individual or family members/carer. Referrals for people in the community (that is, home or residential care), or people requiring an outpatient clinic appointment, can be made by faxing a completed Palliative Care Referral form (PDF 584KB) to your local palliative care service. New referrals will be processed during office hours Monday to Friday 9.00 am to 4.00 pm.

Pharmacists have a role in the care of people with a life-limiting illness. They may be caring for patients within a hospital, hospice, residential aged care home or their community. As a member of the multidisciplinary palliative care team, pharmacists may take on a range of roles and responsibilities. Pharmacists can provide advice on medication management including prescribing (including ‘off-label’ and anticipatory), administration, and deprescribing in line with rational use of medicines. 

palliAGED For Pharmacists provides information and links to resources relevant to contemporary Australian pharmacy practice and the potential role of pharmacists in palliative care, particularly in aged care.

Life-limiting illnesses can cause significant distress and suffering.  Suffering can be described as a multidimensional experience related to physical symptoms, psychological distress, existential concerns, and social-relational worries. Anxiety and depression are also seen in palliative care populations. High levels of distress affect a person’s ability to cope with their illness, its symptoms and its treatment, and with decision making about treatment and care. There are screening tools for distress available including the Distress Thermometer and the K10.

Open and supportive communication, dignity conserving care, and interventions targeting spiritual well-being, maintenance of hope and the sense of self can all be considered when looking at how to support the patient. The Patient Dignity Question provides a meaningful way to support person-centred care. Asking “What do I need to know about you as a person to give you the best care possible?” can enhance your understanding of a patient's sense of self, goals, and priorities, as well as build rapport.

Assessment and referral to a counsellor or specialist provider can also be beneficial.

The emotional demands of caring for someone with a life-limiting illness can be high. Provide them with information about the CarerHelp website and the Carer Gateway website. Carer Gateway offers counselling and online support groups. CarerHelp provides information and resources specific to those people caring for someone who has a terminal illness.

There are tools that can be used to assess the needs families and carers including the NAT-C: Needs Assessment Tool for Caregivers (345kb pdf) and NAT-P&F: Needs Assessment Tool for Patients & Families (91kb pdf).

As a health professional you need to encourage the family and carers to consider their own well-being and health and initiate self-care practices. Where possible, provide information on carer support and respite care services to reduce their burden. Encourage them to set up support networks. The use of apps such as the HELP app or Gather my Crew can be useful.

More detailed information to support GPs and nurses working with carers and families can be found on the CareSearch website.

Patients can have complex needs and may receive care from different health professionals and services. GPs will often co-ordinate care arrangements and may need to confirm after hours support arrangements. If your patient is being seen by a specialist palliative care service, they should have established care processes for after hours.

Extended care paramedics work collaboratively with other health care professionals to manage and treat people in their residence, particularly people who live in residential aged care facilities. To ensure paramedics treat the person according to their wishes, their goals of care must be clearly documented and accessible. Paramedics use a Resuscitation Plan 7 Step Pathway to understand patient wishes and act accordingly.

Developing a clear pathway for after-hours care is an important part of care planning. A contacts list for the family means they know who to ring about what and who to ring after hours.

The Australian Government funds a range of national palliative care initiatives and programs primarily focused on education, training, quality improvement and advance care planning. The Department of Health and Aged Care has produced a matrix document summarising palliative care education and training opportunities for primary care and aged care. CareSearch provides specific palliative care information and resources for different professional groups and settings including: GPs, Nurses, Allied Health, Acute Care, Primary Health Care. palliAGED and ELDAC provide palliative care resources for aged care.