Australian & New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine

The Australian and New Zealand Society of Palliative Medicine (ANZSPM) is a specialty medical society that facilitates professional development and support for its members and promotes the practice of palliative medicine. Our members are medical practitioners who provide care for people with a life threatening illness.

The Australasian Chapter of Palliative Medicine (AChPM) was officially formed by the RACP in 1999 when a second fellowship pathway and alternative entry point was created within the Adult Medicine Division. The specialty became formally recognised in 2005. The Chapter currently has close to 360 Fellows through the RACP and/or AChPM pathways and over 130 current advanced trainees.

Download the ANZSPM and AChPM Evolve Top-5 recommendations (PDF)

Top-5 recommendations on low-value practices

1. Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.

Rationale and evidence

Rationale

Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen.

Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs.

Evidence

Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. Journal of Clin. Oncology 2012; 30(4): 394-400.

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine 2010; 363(8): 733-742.

Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009; 302(7): 741-749.

Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. Journal of Palliative Medicine 2008; 11(2): 180-190.

Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch. Intern. Med 2008; 168(16): 1783-1790.


2. Limit routine use of antipsychotic drugs to manage symptoms of delirium.

Rationale and evidence

Rationale

Effective screening, reversing the precipitants of delirium and providing a variety of supportive non-pharmacological interventions are crucial to addressing delirium in patients in palliative care settings.

Treatment with antipsychotic drugs should only be considered if patients with delirium are in distress and the cause of distress cannot be addressed through non-drug strategies. Antipsychotics are commonly used in the management of delirium in palliative care settings. However, recent research into the management of mild- to moderate-severity delirium indicates that the use of antipsychotics is linked to increased delirium symptoms and increased patient mortality.

Evidence

Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial. JAMA Intern Med. 2017;177(1): 34–42.

Bush SH, Tierney S & Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs. 2017;77(15): 1623–1643.

Clinical Care Standards on Delirium. Australian Commission on Safety and Quality in Health Care. Jul 2016.


3. Do not use oxygen therapy to treat non-hypoxic dyspnoea.

Rationale and evidence

Rationale

Oxygen is frequently used to relieve shortness of breath in patients with advanced illness. However, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air is equally as effective as oxygen under these circumstances. The use of a fan for facial air streaming can also be effective.

Evidence

Chronic obstructive pulmonary disease (COPD) evidentiary framework. Ont Health Technol Assess Ser. 2012; 12(2): 1-97.

Abernethy AP, McDonald CF, Frith PA. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a doubleblind, randomised controlled trial. Lancet 2010; 376(9743): 784-793.

Uronis HE, Currow DC, McCrory DC, et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br. J. Cancer 2008; 98(2): 294-299.

Philip J, Gold M, Milner A, et al. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. Journal of Pain Symptom Management Dec 2006; 32(6): 541-550.


4. Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice.

Rationale and evidence

Rationale

There is no empirical basis for the practice of offering routine referrals to bereavement services to family and care givers of patients in palliative settings. Most bereaved family and carers are resilient and only a small proportion of individuals will develop pathological responses that might not resolve without professional help.

Evidence suggests psychosocial interventions are more effective for people with more complicated forms of grief. Grief is considered complicated when an individual’s ability to resume normal activities and responsibilities is persistently disrupted after 6 months of bereavement. 6 months is seen as the appropriate minimum threshold for complicated grief since studies show that most people integrate bereavement into their lives by this time.

Evidence

Hall C. Beyond Kübler-Ross: Recent developments in our understanding of grief and bereavement. InPsych. Dec 2011.

Schut H & Stroebe MS. Interventions to enhance adaptation to bereavement. J. Palliat. Med. 2005;8 Suppl 1: S140-7.

Schut H & Stroebe MS. Effects of support, counselling and therapy before and after the loss: can we really help bereaved people? Psychologica Belgica, 50(1-2): 89–102.

Wittouck C. et al, The prevention and treatment of complicated grief: a meta-analysis. Clin Psychol Rev. 2011;31(1): 69-78.

Zech, E., Ryckebosch-Dayez, A.-S., Delespaux, E, et al. 2010. Improving the efficacy of intervention for bereaved individuals: Toward a process-focused psychotherapeutic perspective. Psychologica Belgica, 50(1-2): 103-124.


5. To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review.

Rationale and evidence

Rationale

Older patients disproportionately use more prescription and non-prescription drugs than other populations. Evidence shows that such polypharmacy increases the risk of adverse drug reactions and hospital admissions. Medication review with follow up is therefore recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.

Evidence

Lu WH, Wen YW, Chen LK & Hsiao FY. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ. 2015; 187(4): e130-7.

Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Intern Medicine 2015.

Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain : The conSIGUE Program. Pharmacoeconomics 2015; Mar 15. [Epub ahead of print].

Fried TR, O’Leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatric Society 2014; 62(12): 2261-72.

Hajjar ER, Cafiero AC, Hanlon J. Polypharmacy in elderly patients. Am J Geriatr Pharmacotherapy 2007; 5(4): 345-51.



Removal of recommendations | 2019

As evidence and clinical practice advances, Evolve recommendations will reflect these changes following a review. The latest SOMANZ recommendation developments are outlined below.

In 2019 following a review of priorities by the Chapter Committee, recommendations 2 and 4 were substituted with new recommendations to add more specialist physician specific recommendations to the list. The list was then duly consulted with all internal and external stakeholders with an interest and expertise in the subject matter of the new recommendations.


Original recommendation 2

Do not delay conversations around prognosis, wishes, values and end of life planning (including advance care planning) in patients with advanced disease.
Rationale

Advance care planning is a process, which includes choosing a surrogate or alternate decision maker and communicating values or wishes for medical care. Evidence shows that advance care planning conversations improve patient and family satisfaction with care and concordance between patients’ and families’ wishes, reduce the likelihood of unnecessary hospital care and increase the likelihood of receiving hospice care.

Evidence
  • Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: a systematic review and metaanalysis. J. Am. Med. Dir. Assoc. 2014; 15(7): 477-489.
  • Poppe M, Burleigh S, Banerjee S. Qualitative evaluation of advanced care planning in early dementia (ACP-ED). PLoS One 2013; 8(4): e60412.
  • Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340: c1345.

Original recommendation 4

Do not use percutaneous feeding tubes in patients with advanced dementia; instead use oral assisted feeding.
Rationale

Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition.

Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhoea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.

Evidence
  • Teno JM. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012; 172(9): 697-701.
  • Hanson LC. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc 2011; 59(3): 463-72.
  • Sampson EL. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009; 2:CD007209.
  • Finucane TE. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999; 282(14): 1365-1370.


How this list was developed

In 2016, 3 Fellows from ANZPM/AChPM convened a working group to produce an Evolve list for palliative medicine. The RACP Policy & Advocacy Unit assisted this working group in compiling a list of 15 clinical practices which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas.

An email was then sent out to all ANZPM and AChPM members with this list seeking feedback, and whether any items should be omitted and/or what new items should be added to this list. 40 responses to this email were received. Based on these responses, an online survey was prepared containing a list of 12 of the original 15 practices. The survey asked respondents to rate each practice against three criteria from 1 (lowest) to 5 (highest) as well as to nominate any additional practices worthy of consideration. The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question.

Based on the results of this survey which had 114 respondents, the top 5 were selected.

 

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