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Supportive and palliative care

Supportive and palliative care

What changed?

  • For people with cancer who are already uncertain about their future, the uncertainty about the risk of contracting COVID-19 and potentially not being able to receive their planned cancer treatment, understandably has considerable psychological consequences, including anxiety, depression, harmful alcohol use, and lower mental wellbeing.1 In addition, COVID-19 is also likely to have adversely impacted their social support network including family members, spouses, children and friends.2
  • Hospital policies for visitors, varied significantly between States and Territories, including strictly limiting or not allowing visitors to minimise the spread of COVID-19.3
  • In some states, home-based palliative care services were initiated or rapidly expanded to provide care to COVID-19 patients outside the hospital.

Impact of change

  • Supportive care and follow-up care of cancer survivors have dramatically changed as a result of COVID19, with face-to-face appointments replaced with telehealth and many international health services reporting insufficient capacity to respond to cancer survivors’ needs.4
  • Virtual supportive and palliative care enables safe contact between healthcare providers and immunocompromised patients who are particularly vulnerable to serious infection with COVID-195. However, socially-distanced care limits the opportunity for hands-on care and small gestures of support and solidarity, leading to care feeling impersonal for some patients.4,6
  • Inappropriate, inconsistent or sub-optimal delivery of virtual supportive and palliative care may negatively impact the psychosocial wellbeing of vulnerable patients and their carers.4,7
  • Nonetheless, the virtual supportive and palliative care model supports continuity of care and may have future applications for cancer management across the care pathway.
  • Advance care planning promotes autonomy for the patient and their family4 and proactive care coordination,8 but can also help with resource allocation, by preventing unnecessary emergency presentations and hospitalisations.4,9

How can high-value changes be embedded or enhanced?

The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic.

These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.

System-level strategies

  • Developing, implementing and evaluating innovative models to enhance and improve access to supportive care services, including psychology and social services, dietary and exercise advice, geriatric care and rehabilitation and allied health services.4
  • Coordinating resource allocation to plan for potential scarcities in equipment, staffing and access to medications for symptom management.10
  • Improving access and equity of access to appropriate prescription medicines, allowing palliative care services to continue care for patients outside the hospital.7,9 
  • Developing standardised policies and guidance about supportive and palliative care for health services to minimise unwarranted variation in practice, particularly during times of stress on the health system.3

Service-level strategies

  • Increasing confidence among health professionals to incorporate virtual and home care models into practice.11
  • Developing guidance on the appropriate delivery of virtual supportive and palliative care.
  • Promoting use of the Optimal Care Pathways for people with cancer, which encourage patients and their carers to develop an advance care plan, where appropriate, which has multiple benefits such as ensuring his or her preferences are known and respected after the loss of decision-making capacity.3
  • Embedding advance care planning into everyday practice may avoid intensive life-sustaining treatments when unwanted by patients and avoid nonbeneficial or unwanted high-intensity care which may place additional stress on health care capacity and may put other patients, family members, and health care workers at higher risk of transmission of COVID-19.4
  • Establishing a digital wellbeing hub to enable staff, carers, volunteers and their families to access relevant support when they need it, and provide a range of self-care and wellbeing resources designed to aid resilience to the whole cancer care workforce.12

Practitioner-level strategies

  • Implementing and evaluating standardised methods to screen for, and manage, the needs of cancer patients, including with the use of electronic patient reported outcomes measures.2
  • Developing guidance for and promoting advance care planning interventions to health practitioners, including specifically for Aboriginal and Torres Strait Islander populations.13
  • Providing psychosocial support for staff providing virtual supportive and palliative care to avoid compassion fatigue in the workforce.3
  • Developing and reviewing risk and continuity plans to support preparedness and wellbeing of staff in providing supportive and palliative care.6

Patient-level strategies

  • Using validated screening tool to assess ‘fear of COVID-19’, to individualise psychological care, including to regularly assess and address patients’ specific cancer and COVID-19 concerns, including frank conversations about patient preferences for end-of-life care and the worries they may have about surviving hospitalisation. Such consultations can be facilitated by telehealth.4
  • Providing psychosocial support for patients and their carers to prevent psychological distress and carer fatigue. Specifically, normalising anxiety may help and adopting mindfulness, compassion and value-based approaches.2
  • Self-care advice on healthy strategies may be offered by healthcare practitioners including good sleep habits, good nutrition and exercise.2
  • Improving access for patients to optimal culturally appropriate supportive care, including for people living in rural and remote Australia, Aboriginal and Torres Strait Islander peoples, and culturally and linguistically diverse communities.14
  • Increasing consumer understanding of advance care planning, and promoting uptake of consumer resources for advance care planning.8
  • Increasing carer confidence in using personal protective equipment (PPE) through development and promotion of training and guidance documents.3
  • Empowering patients and their carers to administer treatments, such as enemas and subcutaneous or intramuscular injections, for symptom relief.7
  • Enabling access to opportunities and guidance on how to provide feedback to supportive and palliative care providers.7

 

References

[1] Ahmed MZ, Ahmed O, Aibao Z, Hanbin S, Siyu L, Ahmad A (2020) Epidemic of COVID-19 in China and associated psychological problems. Asian J Psychiatr 51:102092

[2] Young AM, Ashbury FD, Schapira L et al. Uncertainty upon uncertainty: supportive Care for Cancer and COVID-19. Support Care Cancer 2020; 28:4001-4. doi:10.1007/s00520-020-05604-9

[3] Cancer Council Victoria. Optimal Care Pathways. Accessed: May 2020; https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

[4] Chan A, Ashbury F, Fitch MI et al. Cancer survivorship care during COVID-19—perspectives and recommendations from the MASCC survivorship study group. Support Care Cancer. 2020; 28:3485-8.

[5] Koczwara B. Cancer survivorship care at the time of the COVID ‐19 pandemic. Med J Aust. 2020 Jun 28; doi: 10.5694/mja2.50684

[6] The British Psychological Society, Division of Clinical Psychology, Faculty for Oncology & Palliative Care. Psychological insights for cancer services recovery planning. BPS, Leicester, UK, 2020.

[7] National cancer expert or consumer participant, Cancer Australia COVID-19 Recovery and cancer roundtable. Meeting minutes unpublished. 30 June 2020.

[8] Victorian COVID-19 Cancer Network. (2020). COVID19 and Cancer in Victoria: Approaches to advance care planning and other important discussions [Video]. Accessed June 2020; https://www.viccompcancerctr.org/victorian-covid-19-cancer-network/webinars/

[9] Palliative Care Australia. COVID-19: Why palliative care matters. Palliative Care Australia, Sydney, NSW, 2020.

[10] The Australian & New Zealand Society of Palliative Medicine (ANZSPM). ANZSPM Guidance - palliative care in the COVID-19 context. Accessed August 2020; http://www.anzspm.org.au/c/anzspm?a=da&did=1005077&pid=1587788101

[11] Dickson H. Hospital in the home: needed now more than ever. Med J Aust. 2020: 10.5694/mja2.50662.

[12] Digital Health & Care Scotland. Scotland’s digital health and care response to Covid-19 [presentation]. Digital Health & Care Scotland, 2020.

[13] Advance Care Planning Australia. Advance care planning in Aboriginal and Torres Strait Islander populations. Accessed: August 2020; https://www.advancecareplanning.org.au/for-health-and-care-workers/in-various-settings/advance-care-planning-in-aboriginal-and-torres-strait-islander-populations

[14] Shukla N, Pradhan B, Dikshit A. A Review of Models Used for Investigating Barriers to Healthcare Access in Australia. Int J Environ Res Public Health 2020;17(11):4087. doi: 10.3390/ijerph17114087