Masterclass 10 - Integrated Palliative Care Service

Evidence points to many benefits of "early palliative care" to improve patients' quality of life while living with a serious illness. Yet most trials of early palliative care have not included patients with hematologic malignancy (HM). Unfortunately, patients with HM are also known to have heavy symptom burden, significant psychological distress, and aggressive care at the end of life, including a greater likelihood of dying in the acute hospital and receiving chemotherapy at the end of life.
To bridge the service gap, an early integrated palliative care (EIPC) collaboration has been established between Haematology Unit of Queen Mary Hospital and Palliative Medical Unit (PMU) of Grantham Hospital since early 2018. HM patients who failed two or more lines of disease treatment with palliative care needs were identified during hematology clinic visit or joint round. These patients will be referred to our PC services including outpatient clinic, home care, in-patient and day care services after screening.
We have a joint hematology palliative clinic in QMH with palliative medicine, haematology , nursing and clinical psychology input. In the first session, HM patients will be firstly seen by hematologist for disease treatment and then transit to our PC team for symptom management and psychosocial care. Ongoing advance care planning (ACP) will be discussed if patients are ready. Their family caregivers will be provided with counselling and emotional support.
There are also regular hematology joint rounds followed by multidisciplinary case conference (CC) in GH PMU. Our team will provide complicated symptom management including pain while the hematologist will be responsible for disease treatment eg target therapy. We have ethical discussions including chemotherapy, blood transfusion frequency, use of antibiotics as well as antifungal. The CC will focus on the patient acceptance, care plan and discussion on bereavement issues. Clinical psychologist will provide opinion on the management of difficult patients or families.
After one-year review of EIPC, the number of referrals to PC was markedly increased. And some of the major symptoms including appetite, depressed mood, itchiness was improved after follow-up visits in hematology PC clinic. Our pilot result also showed that early PC group (≥3 month) had significantly reduction in the total length of stay (LOS) of acute unscheduled admissions for the last 90 days before death when compared with the late PC group.

Promoting collaboration between palliative care (PC) and other specialties through a shared care model according to patients’ needs is one of the strategic directions stated in the Hospital Authority Strategic Service Framework for Palliative Care in 2017. A new Inter-hospital Palliative Care Consultative Service has been established in Kowloon West Cluster since October 2018 under the Framework, aiming to improve PC coverage in acute hospitals, enhance early discharge to community, triage patients with complex needs to Palliative Care Unit (PCU) and to enhance quality of dying for patients who die in place.
Preliminary data analysis included 69 patients served from 2 Oct to 7 Nov 2018. The mean waiting time from referral to PC service was 1 working day, compared to 14 days before the start of the service. The consultative team provided symptom assessment (98.6%), symptom management such as suggestions on medications (56.9%) and opioids (22.2%), psycho-spiritual assessment and support (77.8%), caregivers support including carer stress assessment (98.6%) and management (70.8%). Advance care planning discussion such as discussion on diagnosis and prognosis (98.6%), DNACPR (81.9%) and life sustaining treatment (56.9%) was offered. Among the patients served, 43% was discharged, 35% died in parent ward and 22% was transferred to PCU. Ongoing analysis of the data and evaluation of the consultative service continues to ensure continuous improvement of the service and quality of patient care.

The World Health Organization defines palliative care as a way of caring for people with life-threatening illnesses which focuses on quality of life, through the prevention and relief of suffering by prevention and management of pain and other problems, physical, psychological and spiritual. In 2014, the World Health Assembly Resolution on Palliative Care urged member countries to include palliative care as an integral component of treatment within the continuum of care. 
With emerging new treatment strategies against cancers, there is a growing proportion of patients with advanced cancer, strongly associated with younger age group, using prolonged anti-cancer drug therapy, mostly with palliative intent, and even until near end of life. Although researchers have identified the advantages of early integration of palliative care in oncological treatment, however, many patients are referred to palliative care service only after discontinuation of systemic anti-cancer treatment. The reasons behind low access rate to palliative care could be inadequate resource availability, ignorance or lack of awareness of resources, referrer or patient and family reluctance and restricted service eligibility.
In Mar 2018, we initiated a programme of early psychosocial support for advanced cancer patients undergoing systemic anticancer treatment as a form of integrated palliative care service in oncology treatment. Screening tools are used to measure the stress level of every new patient attending chemotherapy clinic. High scored patients are referred to social workers of oncology team for individual counselling. Trained nurses focus on physical as well as psychosocial complaints of patients followed up in chemotherapy nurse clinics. Streamlined pathway is used to ensure an efficient referral of service from frontline clinical staffs of the department.