This chapter is presented as a processional case discussion reflecting the nature of the palliative phase. At the completion of this chapter, the reader should be able to:

Mrs. Good is an 83-year-old widow, a former nurse who lives alone and the mother of a supportive daughter and son. She has a number of comorbidities including type 2 diabetes, chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD), congestive heart failure (CHF) and hypertension. Despite excellent compliance and maximal treatment, in the last few months, she has become more fatigued, has lost weight and is less keen to mobilize. At a recent review with her general physician, she and her family were gently told and were accepting of the fact that her illnesses were advanced and that her management focus was entering the “palliative” phase.

Palliative care, as defined by the World Health Organization, is an approach that improves the quality of life of patients and their families facing life-threatening illness, through prevention and relief of suffering, by the early identification, impeccable assessment and treatment of pain and other problems. Palliative care affirms life and regards dying as a normal process, intends neither to hasten nor to postpone death and uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated [1].

Traditionally, palliative care has been synonymous with the end-of-life care of the cancer patient; however, it is now acknowledged that palliation can and should be offered to all patients, regardless of age or disease process, who suffer from a life-threatening illness. Moreover, palliation can be offered at any phase of the disease trajectory, in conjunction with active treatment, as an essential part of “supportive care”.

As our society ages and the proportion of people older than age 65 steadily increases, there is a pressing need to integrate two areas of medicine that have been “relatively neglected in the past” [1]. It makes both moral and intellectual sense to focus attention upon the palliative care of the older person.

With the aim of integrating the principles and practice of palliative care into geriatric practice, the following core concepts [2] have been highlighted:

Specifically, it is important to recognize that older patients have “distinct needs in the provision of palliative care” [3]. Older persons:

The family discussion about Mrs. Good’s deterioration and phase change was prompted by her physician’s identification of three triggers [6] that suggest she may be approaching the end of life.

The anticipation of further deterioration allows for the opportunity to discuss preferences and needs in advance of any further serious decline. Resources and support services can be mobilized; plans can be put in place determining the approach and place of care; and caregivers can prepare to mobilize and provide their support.

At home, Mrs. Good deteriorates over a number of weeks with increasing dyspnoea, an occasional non-productive cough and fatigue. One night her daughter visits and finds her very unwell. An ambulance is called, and she is taken to the local emergency department, acutely dyspnoeic and very frightened. A chest X-ray and routine blood tests reveal pulmonary oedema, cardiomegaly and deteriorating renal function, respectively. The emergency physicians (after discussion with Mrs. Good, her family and her general practitioner) treat the symptoms with small doses of diuretic and morphine. A resuscitation plan is put into place.

A smooth transition from home to the hospital emergency department will prevent unnecessary (i.e. futile, uncomfortable and costly) tests and investigations. Ideally the family and primary health team (general practitioner, community and/or palliative care nurses) will communicate directly with the emergency staff about the person’s current condition, the therapies already initiated and any investigations performed and, most importantly, provide formal details of a consensual approach to care, often known as an advanced care plan.

This plan represents discussions about “preferences for future care between an individual and a care provider in anticipation of future deterioration” [1]. The plan can address many goals, including death preparation, assistance in asserting control over the remaining part of one’s life and relieving the burden of care.

From a thoughtful advanced care discussion, several outcomes may arise [1]:

Understanding the goals of care and where the person is located on the disease trajectory determines the palliative management [8]. On arrival at the emergency department, any advanced care plan should be acknowledged by the treating team and discussed with the patient and carers. Once deemed up-to-date and appropriate for the situation, a hard copy should be placed prominently in the medical record. When there is acknowledgement that the approach should be palliative, the clinical focus must then shift from diagnosis and disease management to symptom management, comfort and relief of suffering.

To facilitate the palliative management of the patient, where possible, a quieter emergency bed space should be provided in direct line of sight of the medical station, with provision for family and carers to be at the bedside for support. A gentle symptom history and examination should be performed, supplemented by corroborative evidence from family and carers. Succinct closed questions in the vernacular about everyday function and activity (e.g. Can you walk and talk? Can you eat and drink? Can you “wee” and “poo”? Do you have pain? Can you sleep? Are you worried or frightened? Can you be with your family?) should not overly tire the patient and may quickly reveal areas of symptom disturbance to focus clinical attention upon. Minimally invasive tests and investigations can be performed at this point to elucidate easily reversible causes: if the patient’s clinical condition allows and the burden to the patient is small.