Most patients with advanced cancer or organ failure will be hospitalised at some point or receive much of their care in tertiary care settings. Multiple specialties are frequently involved. The GP has an essential role in ensuring continuity of care, particularly for patients with complex problems. The GP’s knowledge of the patient contributes to a more complete assessment.
In general, planning ahead, documenting the patient’s wishes and advance care plans, and careful communication with carers including aged care facility staff, will reduce problems of continuity of care.
When should a patient be admitted?
Transfer to an acute hospital or a palliative care in-patient unit is sometimes necessary for palliative care patients. Specific situations that may require inpatient management can include:
- For rapid assessment and management of potentially reversible causes of deterioration (where clinically appropriate) such as hypercalcemia
- For rapid assessment and treatment of possible spinal cord compression
- For interventional pain management
- For any symptoms that are unable to be controlled in the patient’s current place of care
- To relieve carer exhaustion.
Important transitions in site of care
For palliative care patients, there are some situations when they may be at risk of receiving inappropriate treatment:
- If requiring transfer by ambulance
- At presentation to an emergency department
- When travelling away from their local area
- When transferred from residential aged care facility to hospital
- If reviewed in a crisis by a medical practitioner who is not familiar with the patient.
Ensuring that some written documentation is available for these situations is good practice.
Communication strategies
Communication strategies vary according to local practice, and for palliative care patients may include:
- Patient held records or letters
- Written advance care plans to be carried by the patient or their carer
- Faxed summaries and electronic medical records to ensure all clinicians are up-to-date with management plans and prognostic information
- Medicalert bracelets, which can also link to information about advance directives
- Case conferences, which can include GPs either face to face or via teleconferencing, to plan and document shared care.
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This page was created on 26 May 2009 and is due for review in May 2011.