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Learning modules

Activity 7: Palliative interventions

Sources of evidence

Palliative symptom management must consider evidence in many forms. The randomised controlled trial is usually seen as the gold standard for obtaining evidence about any intervention. However, there are lots of different types and sources of evidence that can inform clinical decision-making.

CareSearch palliative care knowledge network is an online resource consolidating evidence-based and quality information for various groups within the palliative care community. [1]

Professor David Currow talks about the importance of evidence in palliative care (WMV, 27.8mb)

It's important to be aware that people with life-limiting illnesses may be seeking complementary or alternative approaches to symptom management.

Comprehensive symptom management

Palliative symptom management may differ depending on a range of factors including the stage of a patient’s illness as well as their personal wishes and preferences.

A comprehensive symptom management plan involves:

  • a thorough, holistic assessment
  • identification of appropriate interventions, based on the assessment
  • implementation of the interventions
  • ongoing evaluation of outcomes of the interventions.

Effective management typically requires:

  • an integrated approach: involves multidimensional symptom assessment and management. For example, pain management may include both opioid analgesia and patient education for relaxation strategies to manage the anxiety related to uncontrolled pain.
  • a targeted approach: directed at specific causal mechanisms and factors contributing to the problem. For example, different pharmacological agents might be needed to target different mechanisms or types of pain.
  • a tailored approach: suitable for individual circumstances, beliefs and preferences. For example, patients who do not have caregivers or adequate financial resources may require additional support from the multidisciplinary health care team.

Key components of symptom management in palliative care

Evaluation

It is important to investigate the underlying cause of symptoms and find out the level of disease progression. This may provide a clearer picture as to whether or not the symptom is reversible or if the individual is entering the terminal phase of their illness.

Interventions may be aimed at alleviating:

  1. the causes of the symptom
  2. the effects of the symptom.

Some examples are:

  • symptoms caused by tumour obstruction may be best managed by endoscopic stenting or surgery
  • symptoms caused by oedema, such as raised intracranial pressure, may be best managed with steroids
  • symptoms caused by comorbidities such as gastric reflux may be best managed by proton pump inhibitors and/or dietary modifications.

Remember to:

  • listen to and accept the description given by the individual
  • explore all factors that may be influencing symptom severity.

Explanation and discussion

  • Consider whether new symptoms may trigger discussions around disease progression and end-of-life goals.
  • Provide clear explanations about the causes of the symptom.
  • Discuss possible symptom management options based on individual need.
  • Ensure symptom management plan is consistent with the person’s individual goals and preferences for care.
  • Facilitate family discussion about the symptom management plan.
  • Involve the multidisciplinary team to ensure an holistic approach.

Tailoring symptom management

Develop an individualised symptom management plan. Optimal symptom management requires a multidisciplinary approach.

Consider:

  • the applicability of all available treatment options to the individual’s clinical and personal circumstances. These treatment options may include:
    • surgical
    • disease modifying (e.g chemotherapy/radiotherapy)
    • pharmacological
    • non-pharmacological
  • the benefits vs burdens of treatments from the person’s perspective
  • the individual and family goals of care and personal preferences.

Monitoring of progress

Palliative symptom management requires ongoing monitoring and assessment and often the clinical picture changes quickly. It is important to adopt a proactive approach to symptom management.

Anticipatory prescribing is common practice in palliative care. Symptoms are anticipated before they occur and pharmacological treatment orders are written to be initiated as necessary. [2]

Thinking points


REFERENCES

1. CareSearch. (2009). Finding evidence

2. Palliative Care Expert Group. (2010). Principles of symptom control. In:Therapeutic guidelines: palliative care. Version 3. Melbourne: Therapeutic Guidelines Limited.