ANZSPM is a specialty medical society that facilitates professional development and support for its members and promotes the practice of palliative medicine. AChPM is a Chapter of the RACP’s Adult Medicine Division.
Recommendations and resources
1) Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.
Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen. Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs.
2) Limit routine use of antipsychotic drugs to manage symptoms of delirium
Effective screening, reversing the precipitants of delirium and providing a variety of supportive non-pharmacological interventions are crucial to addressing delirium in patients in palliative care settings.
Treatment with antipsychotic drugs should only be considered if patients with delirium are in distress and the cause of distress cannot be addressed through non-drug strategies. Antipsychotics are commonly used in the management of delirium in palliative care settings. However, recent research into the management of mild- to moderate-severity delirium indicates that the use of antipsychotics is linked to increased delirium symptoms and increased patient mortality.
3) Do not use oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety or routinely use oxygen therapy at the end of life
Oxygen is frequently used to relieve shortness of breath in patients with advanced illness. However, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air is equally as effective as oxygen under these circumstances. The use of a fan for facial air streaming can also be effective.
4) Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice
There is no empirical basis for the practice of offering routine referrals to bereavement services to family and care givers of patients in palliative settings. Most bereaved family and carers are resilient and only a small proportion of individuals will develop pathological responses that might not resolve without professional help.
Evidence suggests psychosocial interventions are more effective for people with more complicated forms of grief. Grief is considered complicated when an individual’s ability to resume normal activities and responsibilities is persistently disrupted after six months of bereavement. Six months is seen as the appropriate minimum threshold for complicated grief since studies show that most people integrate bereavement into their lives by this time.
5) To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review
Older patients disproportionately use more prescription and non-prescription drugs than other populations. Evidence shows that such polypharmacy increases the risk of adverse drug reactions and hospital admissions. Medication review with follow up is therefore recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.
- Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. Journal of Clin Oncology 2012;30(4):394-400.
- Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine 2010;363(8):733-42.
- Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302(7):741-9.
- Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. Journal of Palliative Medicine 2008;11(2):180-90.
- Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168(16):1783-90.
- Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial. JAMA Intern Med. 2017;177(1):34–42.
- Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs. 2017;77(15):1623–1643.
- Clinical Care Standards on Delirium. Australian Commission on Safety and Quality in Health Care. Jul 2016.
- Chronic obstructive pulmonary disease (COPD) evidentiary framework. Ont Health Technol Assess Ser 2012;12(2):1-97.
- Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a doubleblind, randomised controlled trial. Lancet 2010;376(9743):784-93.
- Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008;98(2):294-99.
- Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage 2006;32(6):541-50.
- Hall C. Beyond Kübler-Ross: Recent developments in our understanding of grief and bereavement. InPsych. Dec 2011.
- Schut H, Stroebe MS. Interventions to enhance adaptation to bereavement. J. Palliat. Med. 2005;8 Suppl 1:S140-7.
- Schut H, Stroebe MS. Effects of support, counselling and therapy before and after the loss: can we really help bereaved people? Psychologica Belgica, 50(1-2): 89–102.
- Wittouck C. et al, The prevention and treatment of complicated grief: a meta-analysis. Clin Psychol Rev. 2011;31(1):69-78.
- Zech, E., Ryckebosch-Dayez, A.-S., Delespaux, E. 2010. Improving the efficacy of intervention for bereaved individuals: Toward a process-focused psychotherapeutic perspective. Psychologica Belgica, 50(1-2), 103-124.
- Lu WH, Wen YW, Chen LK, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ 2015;187(4):E130
- Scott IA, Hilmer SN, Reeve E, et la. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Intern Med 2015;175(5):827-34.
- Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The conSIGUE Program’, PharmacoEconomics 2015;33:599-610.
- Fried TR, O’Leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatr Soc 2014;62(12):2261-72.
- Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. American Journal of Geriatric Pharmacotherapy 2007;5(4):345-51.
- Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007;167:781-7.
Last reviewed May 2019
How this list was developed
Fellows from the Australian and New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine (ANZSPM/AChPM) convened a working group to produce an EVOLVE list for palliative medicine. The Royal Australasian College of Physicians (RACP) assisted this working group in compiling a list of 15 clinical practices in palliative medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas. This list was then sent out to all ANZSPM and AChPM members, seeking feedback on whether the items fully captured the concerns of clinicians in an Australasian palliative medicine context and if not, whether any items should be omitted and/or new items added. 40 responses to this email were received. Based on these, 3 items were removed leaving a shortlist of 12. An online survey was then sent to all ANZSPM and AChPM members asking respondents to rate each item against three criteria from 1 (lowest) to 5 (highest), and to nominate any additional practices worthy of consideration. The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question. Based on the 114 responses to this survey, the top 5 were selected.