Background
A model of care broadly defines the way health services are organised and delivered. [2,3] It outlines best-practice care and services through core components (the components describe who delivers which particular intervention, when, where, how, to whom, and for what purpose) and principles that sit within a framework that provides the structure for the implementation and subsequent evaluation of care. [3-5]
End-of-life refers to the period during which people live with advanced illness that will not stabilise and from which they will die. It may or may not be limited to the period immediately before death. [5] Multiple services are required to support these people and their families. The model of care used to deliver these services can affect the quality of the end-of-life care. [5]
Evidence Summary
The framework for Australian palliative care is outlined in the Palliative Care Service Development Guidelines. Palliative care is provided to meet the needs of people living with or dying from a life-limiting illness and to support their families. Not all people at end-of-life will need specialist palliative care but appropriate care when and where it is required care should be available. [1] A palliative approach and general palliative care can be delivered in many settings and by a variety of professionals, including specialists as well as generalists (GPs, nurses, nurse practitioners, allied health professionals, and carers, and volunteers. [4,16] Specialist palliative care can be delivered in settings such as general hospital wards, dedicated palliative care hospital wards, hospices and in the community. [16] Palliative care teams generally include at least one professional with advanced training in palliative medicine. [16]
Various models for palliative care delivery and their components are found in the literature. [2,4] These models are becoming increasingly important as the population ages and as the number of people living with multiple chronic conditions increases. [2-4,7-11] Models need to be dynamic to respond to the changing population demands (including the needs of vulnerable populations), the health system structure and the policy, sociocultural and economic context. [4,8,14,16]
People with serious chronic illnesses and unpredictable times of death, and their families often need support over a long period of time. The trajectory model offers a way to support their intermittent needs, and simple or complex ongoing needs, and build towards palliation being the focus of care. [3,10,11] Care under this model starts early, following a timely referral, even concurrently with potentially curative treatment. [3,10,11] It can also assist a family to cope with the illness and bereavement. [9]
To date, a univocally-agreed model of care for palliative care does not exist as such. [6] A European consortium has proposed a framework for integrated palliative care which pulls together existing validated components of care. The important components of this framework are a multidisciplinary team trained in palliative care with a threefold focus: on treatment (of physical and psychological symptoms), consultation (discussions of care planning and care goals) and ongoing training. [6]
Community palliative care can reduce general health care use and increase family and patient satisfaction with care, which support families to sustain patient care at home. [4,7] There are indications that it increases the chance of home deaths and should be provided for those who wish to die at home but this research is not specific to the care of older people. [4,13,14]
Residential aged care facilities (RACF) provide palliative care. Despite the increasing demand in response to the increase in the older population, there is very little high-quality research about what aspects of palliative care best support residents and their families. [9] Palliative care in a RACF requires effective integration between different providers. Barriers and facilitators for the integration have been identified, but there is limited evidence about an effective integrated model. [12] As with all settings, appropriate outcome measures are required to assess the quality of palliative care provided in residential aged care facilities. [9,15]
Care via a palliative care day centre is a component of a model of service delivery, and systematic reviews demonstrate that attendance at these provide a positive experience. Some evidence shows day care services generate a renewed sense of meaning and purpose for the person [7] yet evidence is lacking in terms of clinical effectiveness and effect on wellbeing. [17,18]
Quality Statement
There is a lack of well-designed randomised controlled trials (RCTs) which compare models of palliative care; existing systematic reviews often focus more on service components rather than models of care. [2] Many studies do not focus on an older adult population or do not clearly report the attributes of the study population. Comparison of different models of care is hampered by diversity of aims, interventions and outcomes. [4]
Page last updated 22 July 2019