Sharing care

Key points

Many patients with advanced life-limiting illnesses have complex care arrangements involving multiple providers. There are associated risks to the patient:

• Fragmentation of decision making, which may not be informed by a holistic assessment
• Miscommunication or delayed communication between clinicians
• Patient burden and cost associated with multiple appointments and settings of care
• Confusion for patients and their caregivers, particularly about who to contact in an emergency, which can lead to inappropriate and unwanted treatment.

The GP has an essential role in relation to specialist palliative care services. However their contribution may be limited by being part-time, or by other practice-related factors. Clarification of the care processes for each patient is therefore critical, including who has responsibility for:

• Maintaining prescriptions for palliative medications
• Regularly reviewing patients’ symptoms, and assessing their care arrangements
• Either being available or ensuring availability of home visiting for patients who are no longer able to attend a GP clinic
• Being available to write a death certificate for patients who wish to die at home.

For palliative care patients, there are some situations involving handovers of care where they may be at particular risk of receiving inappropriate treatment, and planning ahead for these is good practice:

• If requiring transfer by ambulance, or if triple zero is called in a crisis
• At presentation to an emergency department
• When travelling away from their local area
• If transferred from residential aged care facility to hospital
• If reviewed in a crisis by a medical practitioner who is not familiar with the patient.
• Provide a Letter - Use the Model letter template (19kb docx) on your practice letterhead to communicate a patient’s resuscitation status and treatment preferences

Strategies to share documentation can improve the quality and safety of care, and reduce unwanted and unnecessary interventions which may result from poor communication:

• My Health Record have particular value for patients who are being treated in multiple care settings, or whose clinical situation is complex or is changing
• Patient-held paper records eg, health summaries, symptom diaries, and medication lists. Health summaries that include contact information for treating clinicians can be important for patients who are travelling
• Written advance care plans, which describe: who to contact in an emergency, who is the person’s substitute decision maker, and what the patient’s wishes are for treatment in different situations. Once completed, this document should be shared with all treating clinicians and also carried by the patient
• Case conferencing, which can include GPs either face to face or via teleconference, to plan and document shared care, and negotiate care arrangements
• Palliative care protocols exist in the ambulance services of several states (SA, NSW) to allow paramedics to respond in a crisis without being required to transport a patient to hospital. Where such arrangements do not exist, consider providing a written plan of care for the ambulance, to relieve paramedics of the obligation to perform CPR on a palliative care patient who is actively dying, or to transport them to an emergency department.