A framework of palliative care for GPs

The role of general practitioners

In Australia the demographics of death are changing. Today most people die an expected death from one or a combination of various chronic progressive conditions.

The majority of Australians report that they would prefer to be cared for and to die at home, but in reality only a minority achieve this outcome. As most deaths are expected, death can be planned for and required care delivered in a pre-emptive fashion. General practitioners (GPs) have a central role in planning and providing for that care.

The framework of care

The framework of care is a tool for aged care workers, general practitioners and nurses managing older patients with advanced chronic conditions (malignant and non-malignant) more proactively. It can be routinely implemented in general practice, e.g. as part of over-75 health assessment, or during regular visits by this patient cohort.

The trigger question asked to commence the framework, 'Would you be surprised if your patient were to die in the next 6–12 months?', can be answered using clinical knowledge, personal knowledge of the patient, discussions with the patient, clinical intuition, a combination of all or some of those, or by using a prognostication tool.

It is important to recognise that the framework is not about getting the patient prognosis exactly right, but to increase mindfulness of proactively managing clinical needs that typically emerge in the last year of life. Routine implementation of the framework of care can help to ensure that patients receive the right care, at the right time, and in the right place. A likely outcome will be increased satisfaction with GP care.

  • answer to the surprise question: ‘Yes’
  • key clinical process: Advance care planning
  • advance care planning is an interactive ongoing process of communication between a competent person and/or their substitute decision-maker, family/carers and health care providers focussing on the person’s preference for their care in the future
  • answer to the surprise question: ‘No’
  • key clinical process: Case conference
  • the aim of palliative care case conferencing is to identify clear goals of management so that stakeholders are 'all on the same page'
  • answer to the surprise question: ‘No’
  • key clinical process: Terminal care management plan
  • terminal care management plans will vary depending on whether the patient is being cared for in a residential aged care facility or at home. Care of patients in this trajectory is focussed on regular assessment and attention to patient comfort and family distress and comfort.

Related resources

  • Fact sheet

    A framework of palliative care: diagrammatic representation

    ANZSPM

    A framework of palliative care is a tool that uses three prognostic trajectories to support GPs to proactively manage their patient's care as it transitions from curative to palliative and to facilitate a quality end-of-life according to patient preferences.

  • Video

    The Framework of care for GPs caring for older Australians

    ANZSPM

    Professor Liz Reymond (ANZSPM) speaking about the background to the framework for palliative care which aims to guide GPs caring for older Australians in the community at the end-of-life. This framework has been developed and endorsed by The Australian and New Zealand Society of Palliative Medicine Inc. (ANZSPM).

  • Video

    The Framework of care and implementation into general practice

    ANZSPM

    Professor Liz Reymond (ANZSPM) speaking in detail about 'The framework for palliative care for community-based aged care patients' which aims to guide GPs caring for older Australians and provides information on how to implement the framework into general practice. This framework has been developed and endorsed by The Australian and New Zealand Society of Palliative Medicine Inc. (ANZSPM).

  • Website

    CareSearch website

    CareSearch

    The CareSearch website provides trustworthy information about palliative care and advance care planning for patients, carers and families as well as for the health professionals providing their care.