Ask any community nurse and they will say that delivering care for patients who are considered palliative is one of the most satisfying parts of their job. This is not surprising when the main aim of palliative care is to relieve suffering and to improve the quality of the person’s life. Traditionally, the focus of palliative care was on those with a terminal diagnosis of cancer where a clear trajectory is more predictable. However, frailty is a complex long term condition with a less predictable end trajectory and as such, it becomes more difficult to identify when palliative care should be considered.
The following diagram was created from stakeholder and focus group discussions in an attempt to develop a short term palliative support model for older people with frailty. It illustrates the unpredictable illness trajectory associated with frailty highlighting opportunities for a more integrated and palliative approach and a need to anticipate support and care across this journey.
from Bone et al (2016)
In earlier posts on this site, we have discussed the complex care and support needs for people across the frailty trajectory, but when should we consider palliative care? If you are not clear about when this is, ask yourself; “Is the patient at risk of missing out on very important elements of their care as they head towards the end of their life?” When asking, you must also consider the patient’s family as they could also be deprived of the opportunity for improved support at this time.
There is an argument that palliative care should commence on diagnosis of any life limiting condition. This is to allow individualised care and support planning and optimal symptom management as well as the opportunity for early anticipatory care planning discussions. Add frailty to this and consideration should also be given to the person’s physical, psychological and possible cognitive decline as well as their expected inability to bounce back from episodes of acute illness.
Does the surprise question apply in this situation? There is some evidence to suggest that the ‘surprise question’ is useful in identifying when the patient would be considered palliative or would benefit from palliative care support (White et al 2017). The surprise question involves any healthcare professional asking themselves “ …would you be surprised if this person were to die (within a specified time period) such as within the next 6 months or within a year”. This type of question has now been incorporated into a number of clinical guidelines as well as the Gold Standards Framework https://www.goldstandardsframework.org.uk/
If this is the case then you should be considering comfort measures for the patient including de-prescribing of unhelpful medications, a focus on symptom management within the context of a comprehensive geriatric and palliative care assessment, good communications and family support. Please check out the excellent BGS resources highlighted in the end of life blog.
Bone, A.E., Morgan, M., Maddocks, M., Sleeman, K.E., Wright, J., Taherzadeh, S., Ellis-Smith, C., Higginson, I.J., Evans, C.J. (2016) Age and Ageing, 45, (6), pp. 863–873, https://doi.org/10.1093/ageing/afw124
Hamaker, M.E., van den Bos, F., Rostoft, S. (2020) Frailty and Palliative Care. BMJ Supportive and Palliative Care, 10: pp. 262-264. doi:10.1136/bmjspcare-2020-002253
White, N., Kupeli, N., Vickerstaff, V., Stone, P. (2017) How accurate is the ‘surprise question’ at identifying patients at end of life? A systematic review and meta-analysis. BMC Medicine, 15:139 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540432/pdf/12916_2017_Article_907.pdf