Updates

The Palliative Care guidelines have been extensively revised. This update focuses on individualised assessment and management of all patients with a life-limiting illness, directed by the patient’s preferences and goals of care, their prognosis and the potential benefits and harms of management options.

Early discussion about and integration of palliative care allows supports to be put in place and symptoms to be addressed while measures to manage disease progression continue. Patients can consider their life goals, values and preferences and discuss emotional issues; this process can help them feel more secure, knowing that they will be supported whatever happens. New summary boxes outline the principles of palliative care for common life limiting illnesses (eg cancer, dementia) and identify indicators of increasing palliative care needs.

A new topic summarises key considerations in providing palliative care and managing comorbidities in patients with multimorbidity or frailty, both of which can occur alongside a life-limiting illness or be a life-limiting syndrome.

Grief is a normal, yet highly individualised, response to loss; every patient, family member and carer will experience different feelings or reactions to perceived or impending loss. Updated advice clarifies symptoms of prolonged grief disorder and associated risk factors.

The strain from facing challenges associated with a life-limiting illness can present as a range of psychological symptoms (eg distress, depressive symptoms, anxiety). Psychosocial support can improve quality of life; a new figure summarises the psychosocial interventions commonly used in palliative care.

Patients with palliative care needs can experience fluctuations in their will to live and may express a desire to die, or request for their death to be hastened. A new topic provides guidance on assessing and caring for patients who express these wishes.

Advice on managing pain and breathlessness in palliative care has been restructured for usability. A multidimensional approach is recommended, considering the impact of physical, emotional, social, existential and spiritual challenges on the experience of pain and breathlessness.

Opioids are the cornerstone of management for a variety of symptoms in palliative care but can cause adverse effects. Prescribing considerations are outlined in tables for easy reference, along with approximate equianalgesic doses of opioids and example calculations when switching opioids and routes of administration.

Treatment of venous thromboembolism (VTE) in patients with palliative care needs has evolved, with direct acting anticoagulants (DOACs) now considered an acceptable option. VTE prophylaxis is generally not recommended for patients in the last weeks of life.

Catastrophic terminal events (eg major bleeding, acute airway obstruction) are rare and occur suddenly, with death expected imminently; these events sometimes cause significant distress to patients and their families and carers. A new topic highlights planning considerations for patients at risk of such an event and includes drug recommendations for distress but emphasises that remaining with patients to provide comfort is more important than the use of a drug; there may be no time to access the drug, or for it to take effect.

A suite of topics on medication management includes practical information on using continuous subcutaneous infusions and accessing medications.

To optimise benefit from each drug and reduce harm, medication rationalisation (including deprescribing) should be considered early, well before patients are in their last days of life or unable to swallow. A new table provides a stepwise approach to assist with this process of shared decision-making. Advice on rationalising different drug classes is also provided.

The key aims of care in the last days of life are to maintain patient comfort and provide support to patients and their family and carers. To assist prescribing and conversations for this stage of life, a printable table of drugs used for anticipatory prescribing (outlining formulations available on the Pharmaceutical Benefits Scheme Prescriber bag) has been added, along with a table summarising how to explain symptoms and aspects of care to family and carers.