Palliativ Plan

[Eunice Beady]

Palliativ plan er eit dokument som skal sikre samhandling, planlegging og tilrettelegging av tiltak, slik at den som er sjuk og familien kan oppleve tryggleik og best mogeleg livskvalitet. Mlet er vere i forkant av ulike utfordringar, bidra til eit meiningsfylt liv og f fram det som pasienten synes er viktig for seg. Internasjonalt blir prosessen og kommunikasjon rundt ein palliativ plan kalla Advance Care Planning (ACP).

If the person is no longer able to make health care decisions for themselves, a caregiver or family member may have to make those decisions. Caregivers have several factors to consider when choosing end-of-life care, including the older person's desire to pursue life-extending treatments, how long he or she has left to live, and the preferred setting for care.

In addition to improving quality of life and helping with symptoms, palliative care can help patients understand their choices for medical treatment. The organized services available through palliative care may be helpful to any older person having a lot of general discomfort and disability very late in life.

A palliative care team is made up of multiple different professionals that work with the patient, family, and the patient's other doctors to provide medical, social, emotional, and practical support. The team is composed of palliative care specialist doctors and nurses, and includes others such as social workers, nutritionists, and chaplains. A person's team may vary based on their needs and level of care. To begin palliative care, a person's health care provider may refer him or her to a palliative care specialist. If he or she doesn't suggest it, the person can ask a health care provider for a referral.

Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics and certain other specialized clinics, or at home. Medicare, Medicaid, and insurance policies may cover palliative care. Veterans may be eligible for palliative care through the Department of Veterans Affairs. Private health insurance might pay for some services. Health insurance providers can answer questions about what they will cover.

Adriana developed anemia while she was being treated for breast cancer. A palliative care specialist suggested she get a blood transfusion to manage the anemia and relieve some of the fatigue she was experiencing. Controlling her symptoms helped Adriana to continue her curative chemotherapy treatment. Treating her anemia is part of palliative care.

In palliative care, a person does not have to give up treatment that might cure a serious illness. Palliative care can be provided along with curative treatment and may begin at the time of diagnosis. Over time, if the doctor or the palliative care team believes ongoing treatment is no longer helping, there are two possibilities. Palliative care could transition to hospice care if the doctor believes the person is likely to die within six months (see What does the hospice six-month requirement mean?). Or, the palliative care team could continue to help with increasing emphasis on comfort care.

Increasingly, people are choosing hospice care at the end of life. Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life.

At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease's progress.

Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but, in hospice, attempts to cure the person's illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has six months or less to live if the illness runs its natural course.

It's important for a patient to discuss hospice care options with their doctor. Sometimes, people don't begin hospice care soon enough to take full advantage of the help it offers. Perhaps they wait too long to begin hospice and they are too close to death. Or, some people are not eligible for hospice care soon enough to receive its full benefit. Starting hospice early may be able to provide months of meaningful care and quality time with loved ones.

Choosing hospice does not have to be a permanent decision. For example, Dolores was 82 when she learned that her kidneys were failing. She thought that she had lived a long, good life and didn't want to go through dialysis, so Dolores began hospice care. A week later, she learned that her granddaughter was pregnant. After talking with her husband, Dolores changed her mind about using hospice care and left to begin dialysis, hoping to one day hold her first great-grandchild. Shortly after the baby was born, the doctors said Dolores' blood pressure was too low. At that point, she decided to re-enroll in hospice.

It is important to remember that stopping treatment aimed at curing an illness does not mean discontinuing all treatment. A good example is an older person with cancer. If the doctor determines that the cancer is not responding to chemotherapy and the patient chooses to enter into hospice care, then the chemotherapy will stop. Other medical care may continue as long as it is helpful. For example, if the person has high blood pressure, he or she will still get medicine for that.

Although hospice provides a lot of support, the day-to-day care of a person dying at home is provided by family and friends. The hospice team coaches family members on how to care for the dying person and even provides respite care when caregivers need a break. Respite care can be for as short as a few hours or for as long as several weeks.

When a person is diagnosed with a serious illness, they should prioritize early advance care planning conversations with their family and doctors. Studies have shown that patients who have participated in advance care planning are more likely to be satisfied with their care and have care that is aligned with their wishes.

PREPARE for Your Care, funded in part by the National Institute on Aging, is an interactive online program that helps a person fill out an advance directive and express their wishes in writing. This tool is available in English and Spanish.

Families of people who received care through a hospice program are more satisfied with end-of-life care than those who did not have hospice services. Also, hospice recipients are more likely to have their pain controlled and less likely to undergo tests or be given medicines they don't need, compared with people who don't use hospice care.

In the United States, people enrolled in Medicare can receive hospice care if their health care provider thinks they have less than six months to live should the disease take its usual course. Doctors have a hard time predicting how long an older, sick person will live. Health often declines slowly, and some people might need a lot of help with daily living for more than six months before they die.

The person should talk with their doctor if they think a hospice program might be helpful. If he or she agrees, but thinks it is too soon for Medicare to cover the services, then the person can investigate how to pay for the services that are needed.

What happens if someone under hospice care lives longer than six months? If the doctor continues to certify that that person is still close to dying, Medicare can continue to pay for hospice services. It is also possible to leave hospice care for a while and then later return if the health care provider still believes that the patient has less than six months to live.

Most Canadians living with life-limiting illness wish to remain independent and receive the care they need at home or in their community. Improved access to palliative care in a variety of health care settings is critical to making that happen. That is why the Government of Canada has made palliative care a priority.

In August 2017, federal, provincial and territorial governmentsFootnote 1 agreed to the Common Statement of Principles on Shared Health Priorities, including a commitment to work together to improve access to home and community care, including palliative care. To support this work, the federal government is providing the provincial and territorial governments with $6 billion over 10 years. Many provinces and territories are using some of this funding to improve access to palliative careFootnote 2. In addition, the federal government has allocated $184.6 million over five years for home and palliative care for Indigenous communities.

In late 2017, the Framework on Palliative Care in Canada Act was passed by Parliament with all-party support. In the spring and summer of 2018, Health Canada consulted with provincial and territorial governments, federal departments, and national stakeholders, as well as people living with life-limiting illness, caregivers and other Canadians.

"We had great doctors for my father, but none of them understood the importance of the palliative approach. We have so far to go in helping not only the public, but also the health care system understand this wonderful field and why early intervention is so crucial.

These consultations informed the development of the Framework on Palliative Care in Canada (Framework)Footnote 3, which was tabled in Parliament in December 2018. It serves as a reference point to help governments, stakeholders, caregivers, and communities identify common directions and opportunities, share best practices and close gaps. The Framework indicated that it would be followed by an action plan laying out initiatives aligned with the Framework that fall under federal responsibility.

This Action Plan lays out Health Canada's five-year plan to tackle issues uncovered through the development of the Framework. It aims to improve quality of life for people living with life-limiting illness, families and caregivers, and enhance access, quality of care and health care system performance. It complements current financial support to provinces and territories under the Common Statement of Principles on Shared Health Priorities.

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