1. It’s important for a GP to be able to estimate when a patient might be in the last year of life. Can you explain how to use the SPICT tool to do this?
The SPICT (Supportive and Palliative Care Indicators Tool) is designed to recognise key points in the clinical trajectory of individuals with chronic and terminal diseases.1 It can help to identify people with life-limiting illnesses or deteriorating health that may be due to one or more advanced conditions. GPs can then adopt a palliative care approach and plan care as soon as it might be of benefit, rather than only in the last few weeks or days.
SPICT is not about identifying patients for specialist palliative care referral and cannot predict exactly when someone will die. It recommends looking for two or more general indicators of deteriorating health and then some specific clinical indicators. It is being used by a number of primary care-based organisations in the UK (see this article online for further resources).
SPICT can help if you don’t already have 1% of your practice list on your palliative care register or are trying to identify people at risk of acute deterioration and hospital admission.
Remember that, each year, a GP with 2,000 patients should expect around seven deaths from dementia or frailty, six from organ failure such as COPD or heart failure, and five from cancer. Does your practice palliative care register reflect this?
A practice computer audit would identify many of the indicators (see online version for open access link).
Referring to a list of SPICT indicators when reviewing hospital letters or out-of-hours contact reports may help in the preparation of over-75s’ or individual care plans. SPICT can also help to identify nursing and residential home patients who have been referred for district nurse or social services input or who have poorly controlled symptoms noticed at medication review.
SPICT also suggests what to do after an individual is identified, with useful prompts and tips for starting conversations about deteriorating health.
2. What are the main priorities of palliative care patients? What are the key issues for care at home versus care in hospital or a hospice?
People who are facing their own deaths most often talk about being pain free and dying with dignity. Many people explicitly don’t want to be ‘a burden’ to their loved ones. The desire to die at home tends to lessen with age and failing health and in patients with conditions other than cancer. More people express a preference for care, rather than death, at home.
Questions to bear in mind when considering care or death at home for a patient include:
- Is someone willing and able to provide the necessary care over what may be many years? Many older women live alone. Spouses are often themselves living with health challenges.
- Is the home suitable for care provision?
- Is the patient living in poverty? This makes home care and home death even more difficult. Fuel poverty and access to good-quality food may be particular issues for the frail elderly.
- Does the person want the adaptations, special equipment and carers that may eventually seem necessary to clinicians? These, especially for some elderly people, can feel like an intrusion into the private, non-clinical space that is their home.
So, with all this in mind, what to do?
Sensitively discussing advance planning with patients is a good place to start. Thinking in advance can take some of the pressure off in a crisis. As many frail elderly people are keen not to be ‘a burden’, this mindset could work to everyone’s advantage.
Another important step is to liaise actively with nursing homes. Ensure you know full and up-to-date contact details for next of kin. Are other loved ones more important to individual patients? Do potential surrogates know what an individual wants – or do they just think they know? What discussions have taken place to ensure this?
Ensure that patients (and you!) know that exploring priorities is a process, not a one-off discussion.
You should also continue to watch for changes in clinical status; these will determine the urgency of a discussion. SPICT can also help with this. Commonly, there are parallel changes in preferences and these should be asked about.
If a patient is considering social service referral, do not delay this process as access to social care may take up to 30 days while applications are processed. During this time, levels of need and means to pay are assessed by the local council.
Patients and families need to ensure that financial benefits are maximised and compassionate community support may especially help the frail elderly.
first published in Pulse
- Dr Caroline Mawer is a GP in east London with an interest in death and dying
- Dr Sara Ritchie is a GP in Stoke Newington, north London
- Dr Mawer would like to thank Alison Smith, a prescribing support dietitian at NHS Aylesbury Vale CCG and NHS Chiltern CCG