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How do GPs navigate palliative care during a pandemic?


Matt Woodley


30/04/2020 2:32:15 PM

The threat of coronavirus transmission has altered the way palliative care is delivered, but there are many ways GPs can adapt.

Associate Professor Joel Rhee
Associate Professor Joel Rhee believes patients with palliative care needs are particularly vulnerable to the effects of COVID-19.

The danger coronavirus poses to older people is well-documented, with mass deaths in aged care residential facilities already reported in many countriesincluding Australia.
 
Primary care is uniquely placed to assume a leadership role in the delivery of aged care, and Associate Professor Joel Rhee, Chair of the RACGP Specific Interests Cancer and Palliative Care network, believes GPs are needed ‘more than ever’.
 
‘There’s nothing magical about palliative care. At end of the day, it is about providing appropriate, whole-person-centred care during the last phases of a person’s life,’ he told newsGP.
 
‘Patients with palliative care needs are particularly vulnerable to the effects of COVID-19 and the reduction in social interactions that has resulted from physical distancing measures. 
 
‘They are more likely to feel socially isolated. Some might feel anxious that they might not receive the care that they require … [and] their mental health might be affected from social isolation, plus the constant anxiety surrounding COVID-19 and its effects around Australia and the world.’
 
Associate Professor Rhee said while Australia has not suffered the same number of infections and deaths seen in other parts of the world, GPs still need to be aware of the way it has altered the delivery of palliative care.
 
‘Most Australian GPs have not been required, so far, to be directly involved in palliative care for COVID-19-positive patients. However, in light of the ongoing pandemic, significant changes have been made in how GPs care for patients, including those with advanced and life-limiting illnesses,’ he said.
 
‘Consultations via videoconferencing software and the telephone have in many cases replaced the need for face-to-face interactions, including home visits, while prescriptions for medications are often sent directly to the pharmacy to be picked up by the patient.
 
‘This introduces the risk of medication errors, especially delays in obtaining medications on time.’
 
Advance care directives are of particular importance, Associate Professor Rhee said.
 
‘Provision of accurate information specific to the patient is going to be really helpful in putting their mind at ease, especially considering the information overload about COVID-19 in the media and a lot of misinformation going around on social media,’ he said.
 
‘Everyone remains at risk of serious complications of COVID-19, particularly those aged 70 years or higher, and people with pre-existing health issues.
 
‘It is important for everyone, but especially people who are at higher risk, to reflect on their own preferences regarding life-sustaining treatments and whom they want making important health decisions if they are unable to.
 
‘A number of states have recently made changes to their regulations to allow lawyers to remotely witness signatures on things like the will, enduring power of attorney and other documents relevant to advance care planning, without the need to be physically present. Advising patients of this change will help put their mind at ease if they are considering creating or updating these documents.’
 
Likewise, Associate Professor Rhee said it is ‘absolutely appropriate’ for GPs to discuss these plans and provide palliative care via telehealth when required.
 
According to Associate Professor Rhee, relevant issues that GPs should consider when looking after palliative care patients over telehealth include: 

  • ensuring there is a system for the patient to be reviewed in person if there is a clinical need
  • safety-netting – which is especially important when patients are not seen in person
  • a system to ensure medication safety. GPs should ensure that there is clarity on how the prescription will be send to the pharmacist, who will pick up the medication, and how and who should administer the medication.
‘In terms of prescribing S8 medications, in NSW at least, GPs can fax or email the script to a pharmacist, but the physical copy must be sent to the pharmacist within 24 hours,’ he said.
 
‘There is a lot of help available for GPs who need specialist advice on palliative care or advance care planning, so they should feel free to utilise those services.’
 
Department of Health (DoH) information provided to the RACGP clarifies that while it is ‘preferable’ to provide an advance care directive in person, new Medicare Benefits Schedule (MBS) telehealth items mirror equivalent face-to-face items. 
 
Where a GP is satisfied that it is clinically appropriate to work on an advance care directive as part of a telehealth consultation, the DoH would also recommend it is in the context of an established relationship between doctor and patient. However, this is not a condition of claiming a Medicare benefit.
 
The DoH encourages practitioners to consult telehealth guidance released by the Australian Health Practitioner Regulation Agency (AHPRA) in relation to forming clinical judgements.
 
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