April 1, 2023

Unlocking the Secrets of Palliative Medicine

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In this episode Dr Gavin Nimon (Orthopaedic Surgeon) interviews Professor Greg Crawford about palliative medicine. We discuss who is cared for, important skills to have and his aproach to treating palliative patients

Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.

Transcript

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G'day, I'd like to let you know that Aussie Med Ed is sponsored by Tego.

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au That's T E G O dot com dot au As we all face the certainty of our own mortality, the importance of palliative care medicine becomes increasingly clear.

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Palliative care is a specialised medical field that focuses on providing relief from the symptoms and stress of serious illness, with the goal of improving the quality of life for patients and their families.

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In today's episode of Aussie Med Ed, we're going to hear from Professor Greg Crawford, a palliative medicine physician.

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He's going to give us a rundown about palliative medicine.

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I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and it's my pleasure to bring Aussie Med Ed to you.

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And today we're going to hear from Professor Greg Crawford, a palliative medicine physician whose PhD thesis was on depression in palliative care in Australia.

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He teaches at the University of Adelaide and provides tutorials in the Master of Clinical and Health Psychology and the Master of Counselling and Psychotherapy.

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Amongst his many accolades, he's also been recognised by the University of Adelaide with the Executive Dean's Medal, the Vice Chancellor's Award, he's got the John Sands Medal for the RACP, as well as being appointed as a member in the Order of Australia in 2022 for his contribution to palliative medicine and tertiary education.

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It's my pleasure to welcome Professor Greg Crawford.

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I'd like to start by acknowledging the traditional owners of the land on which this podcast has been produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging.

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It's my pleasure now to introduce Professor Greg Crawford.

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Palliative medicine physician who's going to talk to us about palliative medicine in Australia.

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Welcome, Greg.

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Thank you, Gavin.

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It's nice to be able to talk with you.

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It's great to have you on board on Aussie Med Ed, and it's good to hear about such an important topic.

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I thought we could start off by you telling us a little bit about yourself and what palliative medicine in Australia involves.

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Perhaps tell us a bit about

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your daily life.

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Thanks Gavin.

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Palliative medicine refers to the practice of goals of care.

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And so we work very much in a multidisciplinary team and palliative medicine refers to the medical component of that care.

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And so palliative medicine as a specialty has really only been formally recognised since about 2000 when within the College of Physicians they set up A proper structured curriculum and training program to become a palliative medicine physician.

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Before that, there were physicians with a strong interest who trained under the general medicine banner of the college, but also there were many, many doctors working, many from general practice, but other areas without a formal qualification or recognition necessarily that they had specialist skills.

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So, I've been doing full time palliative medicine for more than 25 years.

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I started my early medical career in country general practice.

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I worked on Kangaroo Island for 12 years and really enjoyed that.

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It was births, deaths, anesthetics, road trauma, marriage guidance, living in a community and understanding how families and society worked.

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And I jokingly say my midlife crisis was to retrain.

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and to work in palliative medicine.

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And it's been a really fulfilling and really satisfying change.

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And I really have loved every part of my medical career.

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I love being an intern.

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I loved being a junior doctor.

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General practice was really satisfying, but I palliative medicine has also been a really good thing.

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I feel like it gives me purpose.

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I really enjoy the scope of the medicine and I think that it makes a significant difference for our community in many ways.

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And

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of the patients you treat in palliative medicine, what are the main diagnoses?

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Is it predominantly cancer or are there other types of patients you might treat?

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Yeah, so I think that's, it's really interesting.

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How does somebody become a palliative patient, I suppose?

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And I remember in, as a medical student, one of our lecturers said that life was a sexually transmitted disease or condition with a hundred percent mortality.

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And although that's a bit flippant, what it says is that we are all.

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heading towards an end of this life, regardless of what your belief or faith or sense of what, if there is anything that happens after this existence.

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And so I think that this core essence of palliative care should be a core part of all clinical practice, and I think the core things are a focus very much on patient centered goals.

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Now, all areas of health care espouse patient centeredness, but I think it's Seen in play much more in palliative care, when there's a focus that there is an end of this current life coming.

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So patient centered care, an absolute focus on symptom control, and that's not just physical but psychological symptoms as well, and that's a really big challenge.

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And that it also hangs on impeccable communication, equally something that every medical practitioner needs to have.

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But there's something about people who are facing the end of life and the people around them in that I think it's almost like their brain is high, wired highly so that they hear the words you say.

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And so indiscreet words, words that aren't clear or don't really mean what you want to say, have the potential to be hurtful.

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So day to day life for me is I work in a multidisciplinary specialist palliative care team and in Adelaide we have three adult specialist palliative care teams.

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Not surprisingly, North, Central and Southern, and there is a paediatric service as well.

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And then there are rural services, and in my service, we rotate the medical responsibility between the major components of our work.

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We care for people in our palliative care unit, or hospice.

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We provide community care with home visiting, often with nurses or other team members.

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And we also provide a consultation liaison service in the major tertiary hospital.

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So we don't admit people under our bed card in that hospital, but actually provide advice and support for people who are there with new diagnosis of cancer or other horrible problems.

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So you need to have a life threatening illness, and you have to have needs that are beyond the care and management of the treating team.

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And so the sort of people we meet People with cancers, metastatic cancers, and of the referrals to our service, probably something like 75 to 80 percent of people have cancer.

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But other people have heart failure, COPD is a very big problem, neurological degenerative conditions.

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So we meet many people with motor neuron disease quite early in the disease trajectory.

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We don't see so many people with Parkinson's disease or multiple sclerosis, and we do see some people with disability, such as head injuries, but often when something else comes along as well.

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Pediatric palliative care has quite a different profile.

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They would have a minority of their patients with cancer and many with all sorts of other metabolic and other developmental and congenital problems.

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And I think the challenge for us is to say, well, who aren't we meeting?

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Who aren't we caring for?

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Uh, and so the obvious is that there's a huge number of people with dementia and dementia is a terminal illness.

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And there are many people who, uh, say in rural areas, don't get access so easily to somebody with my skills.

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So we have a, an excellent network in South Australia, but people are, who have culturally and linguistically diverse backgrounds, refugees, prisoners, homeless people, gay, lesbian, transgender, all those sort of, uh, people who might.

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be labelled, though it's not a really nice word, I don't think, vulnerable, but, uh, people who are not mainstream are more likely to miss out on some of the things that we could offer.

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So it's your

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goal to try and make this more inclusive,

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this area as well?

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Oh, absolutely.

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We, we, we think really carefully about who we're meeting and most of us would espouse that we should have a population based approach to our care.

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So it's not Just who gets referred to us, but who else might need care.

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And I suppose it's important to say that not everybody needs a palliative medicine physician to be involved in their care or in their dying.

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General practitioners are very skilled and before the establishment of this discipline as a specialty, more people were cared for by the general practitioners.

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It's harder for GPs to admit people to hospital nowadays.

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It's harder for GPs to coordinate the care around somebody at home, particularly if somebody wants to die at home, without the input from our team because of the way community services are structured now.

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I'd like to let you know that Aussie Med Ed is supported by Healthshare.

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Healthshare is a digital health company that provides solutions for patients, GPs and specialists across Australia.

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Two of Healthshare's core products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, with the aim to reduce admin and free up time during a consult, and Healthshare's specialist referral directory.

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You can find out more from healthshare.

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com.

00:10:20.548 --> 00:10:36.259
au Do you think there's a big role for like PR for palliative care to actually make it more available, make it more known about for these vulnerable groups so they're aware of what's

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available?

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Oh, I think PR is a great term, Gavin.

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I think that most people don't want to meet a palliative care doctor.

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When I meet people, talk about being somebody who wants to help them live every day there is, but acknowledge that death is part of the outcome that we're expecting.

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Now, how you introduce that thought and actually talk about that is something a bit like breaking bad news, and it's a very sensitive conversation, so you pace it with the person involved.

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But I think most people are ready and open to talk about what's happening to them.

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And many people are able to talk very clearly about what they would want and what they don't want as the end approaches.

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And so I think the skills of helping people to face what's coming in a safe way that doesn't take away their hope, it helps them make the choices that they would want to make at a time like this.

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are important.

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I think sometimes wouldn't it be terrible if somebody was lying on their deathbed and I said, and they said to me, Doctor, I wish you'd told me more clearly what was going to happen because I wouldn't have done this or I would have done that or, and uh, so I think that's an important part of the work we do.

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But also, The other part is the benefit for the people around that person who has this illness and wider community.

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I think that if somebody can look back and think, this has been awful, you know, death is death.

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But if this has been the best time that it possibly could have been, that these people feel supported, they know that their loved one had good symptom control and made the decisions they wanted to.

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make that those people are more likely to not get over their grief, you never get over grief, but are able to put it in a place where they can return to productive living more quickly.

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And I think that's a really important aspect of the care that we provide too.

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So listening to you speak today, two words come to mind.

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Respect and support for both the family and for the patient themselves.

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Is that a good way of thinking about palliative medicine as a way of describing the key tools you need to have?

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I think absolutely, Gavin, because we believe that every day of life is valuable and a person has the right to control what they want to do with whatever time there is left.

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It's interesting, the medical students who have clinical attachments with our service, they invariably say to us, that they really see a multidisciplinary team working at a high level and see the support of each other that happens and the focus on our patients.

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And we're really very busy.

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We're hammered, I think.

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Our clinical workload seems to have got more difficult in recent years and I think COVID and all those sorts of things.

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really challenge some of our philosophies and some of our practices, but I think respect and support are really good words to describe it.

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And going

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on to the different members of the group, of the team that make up a palliative care, you've already touched on some of them.

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Who are the, all the

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members on the team?

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We have a very strong nursing focus to our teams.

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And so we have community nurses who help coordinate care.

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And then we coordinate with community nurses like RDNS and Calvary Care, who are a separate organization, but we have a close working relationship.

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Our nurses, we have Level 2 and Level 3 nurses, and we have nurse practitioners.

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And in our service, our nurse practitioners work in the community.

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They can prescribe, they can order tests.

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We work very collaboratively.

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It's not like they're individual practitioners, just like Doctors, medical practitioners are individual.

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We work closely together.

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Within our medical team we have consultants like myself.

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We have registrars and most of our registrars are advanced trainees in palliative medicine.

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Currently we have somebody who's training towards rural general practice and doing a special skilled post in our service.

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To enter advanced training in palliative medicine, you either come through a physician pathway and do that basic physician exam, or you can, with a fellowship of about eight or nine recognized other colleges, then start advanced training.

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And so, The same training is provided to advanced trainees, whether they've come from general practice, surgery, even, Gavin, orthopaedic.

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So I don't know of any orthopaedic surgeons who have retrained in palliative medicine as those who've come through physician training.

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There's also a diploma in palliative medicine, which is a six month clinical job that is probably very suitable for GPs or oncologists or somebody who wants to say that they've got some special skills but are not a specialist in palliative.

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Medicine as well.

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And we have interns and residents working on our wards as well.

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So our team has a large group of social workers and they spend a lot of their time navigating my age care, NDIS, counselling, financial issues.

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Housing issues are even a significant problem.

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And then we have a pharmacist in our team who's a really valuable member on the ward, but also in our community we have access to clinical pharmacy.

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Variably, we have physios and OTs who are really important in helping us set up plans of care for people.

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So, I'm sure you understand our physios don't do lots of exercises and strengthening.

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Their roles are much more around supporting our team to know how to safely care for somebody, assessing whether they need equipment.

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Anticipation would be another one of the words in our team to try and be ahead.

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So we always like to have a plan A and a plan B and we don't like to have crises.

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We'd much prefer to see something coming and plan for it.

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Volunteers are an important part of our team.

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They got a bit difficult during COVID, but volunteers are really important part of the working as well.

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What about psychologists and

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psychotherapists and things?

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to give support

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that way as well.

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Oh Gavin, you've touched a sore spot in my heart.

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My doctoral thesis was about depression in terminal illness and we've not been able to successfully embed a psychologist into specialist palliative care, despite several opportunities with different sorts of funding.

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But I think the challenge has been that the funding we've been offered has been short term and not relatively significant skill level.

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for what we need.

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Psychologists would be such a great addition to our team for the patients and their family but also for our team's better functioning and to develop our own team's understanding.

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I've been working with one of my psychology colleagues at the University of Adelaide and trying to build research projects that embed some psychology into it so that we can show the value.

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but also that hopefully we can embed somebody who then has a passion and would like to take it further.

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Obviously

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it's an important issue.

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Moving on, what are the other areas where patients can be cared for apart from a hospice or being cared for at home by a GP?

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Where does things like Ronald McDonald House fit in and how do they all tie together?

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I think that's a really good question.

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Gavin, if you asked the man in the street where they would like to die, if that was coming, if you asked a healthy South Australian, somewhere between 58 and 70 percent of people would say, I want to be at home.

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If you asked elderly people, if you asked Women, if you ask more highly educated people, you're going to get less people saying I want to be at home, because I think the reality of dying at home, when you realise that your partner is equally elderly, or you are living alone, or you have children who are looking after their own children, it makes the whole issue of dying at home a bit more of a challenge.

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But in Australia, probably 14 percent of people actually die at home, a predicted death, where, you know, 58 to 70 percent would say they would want to die at home.

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If you're referred to our service, we Frequently, uh, are able to help people to die in the place of their choice, but equally those who want to die at home, somewhere in the order of 40 to 50 percent at least.

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Um, but where else do people die?

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Well, our palliative care unit, we call it a palliative care unit rather than hospice, um, because it's quite an acute unit.

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Our average length of stay is about eight days.

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And so it's not a place where people come and stay for months and months and quietly die.

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We have people who are still having chemotherapy come to our palliative care unit.

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We give intravenous antibiotics.

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We transfuse people.

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We treat hypercalcemia.

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We manage and drain ascites and pleural effusions if that will improve patient's symptoms and consistent with their goals of care.

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But we don't want to take over the care of active oncology either.

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So there are people who spend a lot of time at home with the support of their families, with the community services that we can put in place, who then might come into our palliative care unit for the end of life.

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There are a significant number of people who go to residential aged care facilities, and they've really become the slow stream hospices of our society.

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But I think it's true to say that they've not been properly resourced to fully meet the need of those sort of people.

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There are some recent reports that show that if you were able to increase the input of specialist palliative care services into residential aged care facilities, we would save the health budget money.

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We, in fact, would save money.

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We would make money for them, but every dollar spent, you would almost make four dollars.

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It's an extraordinary statistic, but it's different silos in healthcare.

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So we visit residential aged care facilities and support GPs caring for their patients there.

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We visit people at home and support them there.

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But still 50 percent of South Australians die in acute hospitals and that's not necessarily inappropriate.

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I think there's been a, if you read some of the literature and policies, you'll see things about inappropriate acute hospitals.

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But some of the evidence shows, and it's not surprising really, that people get better symptom control at the end of life in hospital.

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And I would hope that, and I'm sure they do get good symptom control in our palliative care unit.

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And that there's probably a bit of a trade off if you're at home, that you don't have quite response to symptom issues if you're at home.

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But our community care system, we have visiting by doctors, nurses, social workers and allied health staff to our patients at home anticipating problems.

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We provide a 24 hour phone advice service.

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by our doctors or senior nurses with doctors back up 24 hours a day to those people referred to our community teams.

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We provide advice to clinicians of any sort within our catchment area.

00:22:30.624 --> 00:23:12.365
We've worked very closely with extended care paramedics, so the ambulance service, the top of the trained personnel, the clinicians in the ambulance service, And so they will visit our patients in the wee hours of the night if they need to be seen, and they can seek advice from us, and we often do joint consultations to help keep somebody at home, or we frequently will try and do direct admissions into our palliative care unit if we have a bed available and understand the problem, because they will then be assessed and reviewed by the hospital medical team rather than the emergency department.

00:23:13.365 --> 00:23:21.954
Sometimes coming through the emergency department is the safest and best way of making an accurate assessment if somebody does need to come into hospital.

00:23:22.244 --> 00:23:30.394
And some of our patients even go for a little bit of rehab and other things to try and improve their function so that they have specific goals.

00:23:30.535 --> 00:23:32.825
So I think that's answered that question, Gavin.

00:23:33.134 --> 00:23:34.384
That's a brilliant summary, Greg.

00:23:34.384 --> 00:23:34.454
I

00:23:34.454 --> 00:23:35.394
really appreciate it.

00:23:35.974 --> 00:23:43.960
Thinking about the last few stages of the patient's care, I would have thought it was very similar to like an anaesthetic analgesics.

00:23:44.660 --> 00:23:48.160
sedation and maybe anti anxiety type medication as well.

00:23:48.460 --> 00:23:51.019
Is it similar in that sense or is it a different sort of

00:23:51.019 --> 00:23:51.730
process?

00:23:52.529 --> 00:24:15.189
I think first, Gavin, it's important to say that not everybody needs a doctor to die and that people have been dying without doctors for centuries but, you know, I think none of us would want to feel out of control, anxious, be in pain, have terrible nausea and so most people do need some sort of medical intervention.

00:24:15.804 --> 00:24:24.933
And so of people referred to palliative care, the sort of statistics around symptoms are that probably 90 percent of people have fatigue.

00:24:25.124 --> 00:24:27.714
Now, that's a symptom that we're not very good at treating.

00:24:27.724 --> 00:24:31.503
It's something we probably don't ask about, but it can be overwhelming.

00:24:32.294 --> 00:24:37.684
Probably 70 percent of people have pain, 50 to 60 percent would have nausea.

00:24:38.294 --> 00:24:46.855
Breathlessness is probably less, but the impact of some symptoms like pain and breathlessness are quite serious too.

00:24:47.464 --> 00:24:53.494
If you're feeling short of breath then you're going to feel very anxious and it's not a very pleasant symptom.

00:24:54.213 --> 00:25:00.994
And the other part is that people become quite weak and so they may not be able to swallow their medications.

00:25:01.434 --> 00:25:15.084
There's a time for rationalizing some of the things that might have been started with, you must take this for the rest of your life, and it should have had until there's, it's benefit is no longer for you, so.

00:25:16.025 --> 00:25:33.574
Anti, you know, anti lipid medications are designed to minimize atherosclerosis, prevent strokes, heart attacks, but they are a five to ten year proposition, so people shouldn't be swallowing their statins at the end of life generally.

00:25:33.865 --> 00:25:44.914
Anticoagulation is a bit more difficult because nobody would want to provoke a stroke, but equally if somebody's starting to have falls, then the risk of cerebral hemorrhage.

00:25:45.244 --> 00:25:49.555
probably becomes greater than the benefit you're getting from the anticoagulation one.

00:25:49.785 --> 00:26:05.624
So there are some complex decision making there, but most people will need something for pain, something for nausea or vomiting, and often a little bit of sedation to help for anxiety.

00:26:05.624 --> 00:26:07.374
It improves pain control.

00:26:07.374 --> 00:26:13.285
If metastases and things like that, then convulsions might be more of an issue.

00:26:13.700 --> 00:26:22.890
It is possible our legislation in South Australia is world leading, really, in that it clearly gives the framework for caring for people at the end of life.

00:26:23.388 --> 00:26:38.609
It talks about the intention of care so that there is no impediment to me within good medical practice providing whatever dose of pain relief that somebody might need, even if there is some concern about whether it might shorten somebody's life.

00:26:39.029 --> 00:26:45.089
In fact, there are some, there's some research that suggests that good pain control actually improves and lengthens people's lives.

00:26:45.789 --> 00:27:08.098
And there's a seminal study probably 10 years ago of people with lung cancer that an early palliative care intervention with patient centeredness, considering unmet needs, explaining what's going on and helping people talk about what their goals in life might be, actually improves survival.

00:27:08.358 --> 00:27:09.279
They didn't just make.

00:27:09.740 --> 00:27:18.720
quality of life better for these people, actually lived longer above and beyond the effect of any chemotherapy type interventions.

00:27:18.999 --> 00:27:23.038
And so many people need subcut medications.

00:27:23.049 --> 00:27:27.398
Subcut is the routine that we use in Australia and the United Kingdom.

00:27:27.819 --> 00:27:33.689
In America, they're much more focused on intravenous medication administration near the end of life.

00:27:34.384 --> 00:27:57.513
And syringe drafts, continuous subcut infusions are probably one of our hallmark interventions because it means that you can set up what you think somebody needs for 24 hours in terms of analgesia and other medications and then just need top up doses or breakthrough medications and we teach families how to give those.

00:27:57.535 --> 00:28:05.484
A nurse would change the syringe driver and the order would be assessed by a medical practitioner or a nurse practitioner.

00:28:05.775 --> 00:28:09.494
So people do, they would be the most common medication.

00:28:09.505 --> 00:28:12.325
So we, our trainees learn a lot about opioids.

00:28:12.365 --> 00:28:18.375
We learn a lot about analgesia, about pain histories, but also symptom control in its broader sense.

00:28:18.664 --> 00:28:21.174
What about the role of cannabis based medication as well?

00:28:21.194 --> 00:28:23.535
Does it have a role to play or has it not been proven in this

00:28:23.535 --> 00:28:24.015
area?

00:28:24.634 --> 00:28:26.434
Oh, thank you Gavin for the question.

00:28:26.434 --> 00:28:27.674
I really appreciate it.

00:28:28.295 --> 00:28:49.484
I've just been part of three or four international systematic reviews of the place of cannabis in palliative care symptoms for pain, for gastrointestinal symptoms like nausea and vomiting, for psychological symptoms, depression and anxiety, and then another paper reviewing all the literature about harms and benefits.

00:28:50.444 --> 00:28:54.075
And there's been an explosion in research about cannabis.

00:28:54.460 --> 00:29:01.119
But there are still very few high quality studies that answer the questions that we need at the end of life.

00:29:01.869 --> 00:29:13.828
And basically, I think the bottom line is that if somebody is taking medicinal cannabis, somebody should be counting data, whether that's part of a clinical trial or some bigger database.

00:29:15.170 --> 00:29:22.529
The challenge for the studies is that when you try and recruit somebody to a cannabis study, everybody wants to be on the active arm.

00:29:22.539 --> 00:29:25.769
Nobody wants the risk of being on a placebo.

00:29:26.190 --> 00:29:32.750
That many of these people are not naive to cannabis, that they've been using cannabis previously.

00:29:33.035 --> 00:29:41.835
And it's a bit like the carts come before the horse in that our approval agencies have actually approved some products for use.

00:29:42.585 --> 00:29:45.454
Um, one of their indications is for palliative care.

00:29:45.454 --> 00:29:54.954
Now, palliative care, as I hope you've understood from what I've talked about, is a very complex and broad and interesting area of endeavour, but it's not just one symptom.

00:29:54.954 --> 00:29:55.755
It's not like it.

00:29:56.315 --> 00:30:01.140
And so, I think cannabis, we're yet to know exactly where it fits in.

00:30:01.740 --> 00:30:08.960
I'm sure that it will have some benefit in nausea, but we've got excellent anti nausea medications.

00:30:08.980 --> 00:30:13.109
Most of them have been developed since the early cannabis studies about nausea.

00:30:13.529 --> 00:30:20.900
They were comparing cannabis with metoclopramide only, and there are a whole lot of other medications since that we know about.

00:30:21.279 --> 00:30:27.078
There are some indicators that some cannabinoids actually make cancers worse.

00:30:27.740 --> 00:30:29.940
and some that make cancers better.

00:30:30.619 --> 00:30:34.769
So it seems to be, in my mind, it's a bit like digoxin.

00:30:34.829 --> 00:30:49.579
When it was first detected and used, it was part of a homeopathic or naturopathy or the old wives tales or, you know, people would mix up potions and some patients got better and their heart failure got better, but some patients died.

00:30:49.650 --> 00:30:55.190
And now we understand about toxic levels and therapeutic levels of digoxin.

00:30:55.599 --> 00:30:59.335
So, I think cannabis will fit there as well.

00:30:59.884 --> 00:31:01.035
So it will have a place.

00:31:01.434 --> 00:31:07.154
At the moment, there's a challenge about THC, the active, psychotropic active agent.

00:31:08.154 --> 00:31:10.075
Could you drive if you've had that?

00:31:10.634 --> 00:31:13.684
Well, I've heard varying opinions about that.

00:31:14.125 --> 00:31:21.315
When you grow cannabis, there are at least 500 active components in that bud.

00:31:21.704 --> 00:31:27.035
And so probably the last patient I sent to ICU had changed their cannabis supplier.

00:31:27.664 --> 00:31:32.484
Homemade resin and became totally comatose.

00:31:32.505 --> 00:31:35.134
So these things are not without side effects.

00:31:36.480 --> 00:31:44.960
It's like everything, we're trying to balance the risks and the benefits and in palliative medicine, we've only really got one shot at getting it right.

00:31:44.979 --> 00:31:47.890
It's not like there's years of life ahead.

00:31:48.140 --> 00:32:02.308
And so I think that's what makes this work really interesting, but challenging in that you want to get the best effect as quickly as you can with the least amount of side effects so that people can, and most people want to have a clear head.

00:32:02.640 --> 00:32:06.970
Good symptom control so they can get on with making the most of whatever time is available.

00:32:07.430 --> 00:32:10.970
And what role is there for the support of the relatives after the terminal event?

00:32:11.049 --> 00:32:13.440
How does palliative care actually cater for that?

00:32:14.079 --> 00:32:24.420
So our service has a bereavement program and bereavement is considered a component of palliative care and we have a WHO definition of palliative care.

00:32:25.049 --> 00:32:29.009
And so it says that it start, it continues after the death of the patient.

00:32:30.410 --> 00:32:39.519
But there's been lots of study about what is the best intervention to help somebody after their loved one has died.

00:32:39.529 --> 00:32:42.920
And as I said earlier, you don't ever get over grief.

00:32:43.789 --> 00:32:47.949
And some griefs are probably harder to bear.

00:32:48.190 --> 00:32:56.049
But we have bereavement support services, we provide counselling, we write cards to people from the clinical team.

00:32:56.329 --> 00:33:00.950
But being bereaved is quite a lonely place to be for many people.

00:33:01.884 --> 00:33:03.744
even with lots of people around you.

00:33:04.474 --> 00:33:13.703
And the challenge is that there are bereavement risk indexes that we can look and say, is somebody more likely to have difficulty in their bereavement?

00:33:13.703 --> 00:33:15.394
And they're pretty obvious.

00:33:15.404 --> 00:33:30.219
Somebody who is socially isolated, somebody who's had a previous grief, somebody who's had an ambivalent relationship with the person who's died, um, somebody who's had a pre existing depression, are all more likely to have bereavement.

00:33:30.410 --> 00:33:32.750
Difficulty in a bereavement period.

00:33:34.275 --> 00:33:43.104
But the evidence suggests that we can't predict very reliably, and so there are people who we think are at low risk who suddenly have a terrible problem.

00:33:43.775 --> 00:33:51.974
And so we try and provide information and support, but general practitioners provide a lot of brief counselling.

00:33:52.594 --> 00:33:55.375
There are many chaplains and other.

00:33:55.894 --> 00:34:01.926
Religious affiliated and spiritual carers in our community who provide care.

00:34:01.926 --> 00:34:14.393
I think some of those clubs that all stopped during COVID really like, um, going down to the RSL club are grief groups really in some level as well.

00:34:14.474 --> 00:34:48.760
But If one of your acute hospital patients dies, you know, there are very few structured bereavement programs for people in acute hospitals unless they've been referred to a palliative care service and that seems grossly unfair to me and I think there's a need for much more education about what grief is, there's a need for much more education about who can provide the support and to skill up, you know, to improve the skills of GPs, nurses, orthopaedic surgeons, even Gavin, about how to cope with grief.

00:34:49.099 --> 00:34:57.989
And I suppose that's the essence of palliative care in that we work in a multidisciplinary team because we can't meet all the needs of any one patient.

00:34:58.110 --> 00:35:17.920
So we talk about the physical, the social, the psychological, the spiritual needs of somebody, and that's why you need a team, so that you can actually say, well, I hear, I listen, tell me more about what's going on, and then here are some other options or supports to help people navigate whatever the problem is.

00:35:18.764 --> 00:35:21.795
It's interesting you make the point about the demands of a clinician nowadays.

00:35:22.195 --> 00:35:26.855
You think there's a role for technology to take the stress off the clinicians so they can focus on a more personalised approach?

00:35:27.534 --> 00:35:30.824
And leave the more mundane tasks to technology.

00:35:31.344 --> 00:35:45.244
Some of my research has been into some of the technologies we use and not just electronic medical record systems and telehealth and telecommunications, which have certainly changed much of our practice.

00:35:45.324 --> 00:35:52.014
But there is virtual realities to try and see if you can give people experiences, you know.

00:35:52.710 --> 00:35:59.309
I wanted to go back on my holiday to Bali once more, and it's not possible, or I always wanted to fly.

00:35:59.340 --> 00:36:01.489
What's it feel like to be in a helicopter?

00:36:02.159 --> 00:36:10.614
Or using virtual reality as a way of distracting from what's happening, as a way of having a bit of Time out, if you like.

00:36:10.824 --> 00:36:28.764
Certainly within rehabilitation, you can have smart houses that can almost watch somebody, and it's a bit of an ethical challenge about consent to being watched, I suppose, but can tell you if the toilet's been used, how often the fridge door's been opened, has somebody opened the front door.

00:36:29.434 --> 00:36:35.954
Palliative care patients, though, our patients are deteriorating, they're not static or they're not improving.

00:36:36.525 --> 00:36:41.125
And I think that makes a challenge for technology for our patients themselves.

00:36:41.125 --> 00:36:45.195
So many of our patients are very involved in technology.

00:36:45.465 --> 00:36:50.965
Some of them have apps around managing their medications that I think are really impressive.

00:36:51.179 --> 00:36:55.789
Could somebody diagnose and talk to a palliative care patient?

00:36:55.809 --> 00:36:58.570
Well, I'm sure that artificial intelligence will do that.

00:36:59.280 --> 00:37:06.398
In Japan, I believe there's a robot that will actually pat somebody's hand and speak to them and try and say it's all right.

00:37:07.150 --> 00:37:27.335
Now, but I still am convinced that the therapeutic relationship of a clinician, and I believe even a medical practitioner, who says, I'm here to support you at this terrible time, and here's a structure of support around you, is a really part, important part of what we do.

00:37:28.074 --> 00:37:47.923
And so it's how we use new technologies to make sure that we're actually not losing the essence of what we do, but we enhance it, can, as they say, scale it up, make sure that more people are getting what they need so that they can achieve the best, even though the end of their life is approaching.

00:37:48.389 --> 00:37:48.639
On that

00:37:48.639 --> 00:37:54.369
basis, what about the role of the family pet, the family cat or dog being involved in the support of the patient undergoing

00:37:54.369 --> 00:37:55.269
palliative care?

00:37:55.489 --> 00:37:56.449
We love dogs.

00:37:56.518 --> 00:37:59.409
They come and visit our patients in our palliative care unit.

00:37:59.420 --> 00:38:05.778
There's no impediment to them coming into what is a ward on an acute hospital really.

00:38:06.039 --> 00:38:14.119
There are a few caveats, you know, we don't like them to stay overnight, but we've been pushed a few times by patients who wanted to have the dog in the corner.

00:38:14.820 --> 00:38:19.510
They have to be continent and well behaved and they certainly mustn't bite the staff.

00:38:19.800 --> 00:38:21.869
Yes, we have pets that visit.

00:38:21.920 --> 00:38:25.219
We've got a little pony that comes to visit some of our patients.

00:38:25.219 --> 00:38:43.250
Now, I'm not quite so sure about the pony, but I'm told that it's a great hit and I know that the pony has come along when we've had some parties, particularly some of our patients who've had children and they wanted to have a celebration, an early Christmas in our day room or do things like that.

00:38:43.425 --> 00:39:02.114
So taking a family history I think is a really important thing and I draw genograms where you put the patient and their close important relatives, their children, their family, and I think the animals need to be part of that genogram as well to know what are the important people in a person's life.

00:39:02.980 --> 00:39:09.739
Now, another thought that comes to mind is the carer, yourselves and the registrars that care for these patients going to the going palliative treatment.

00:39:10.210 --> 00:39:11.130
How do you cope with it?

00:39:11.130 --> 00:39:21.099
I know you do your music and I've heard you play, you're very good, but how do you actually learn to cope with looking after patients who are dying and what do you advise the registrars going through the program?

00:39:21.710 --> 00:39:33.940
We talk openly about self care within our training programs for different disciplines and within our teams, and I think that is a bit different to many other areas of health care.

00:39:34.469 --> 00:39:44.010
We still have a hierarchy of leadership and we have to achieve certain things, but we are much more of a level team, if you like.

00:39:44.269 --> 00:39:48.179
So we look out for each other and, Pio, you know, some would say, are you all right?

00:39:48.210 --> 00:39:48.980
What's happening?

00:39:49.179 --> 00:39:56.659
And I think that what we do know is that it's usually the work, caring for dying people is not dangerous.

00:39:57.210 --> 00:40:13.570
Sometimes some situations pull all the strings, you identify with them as Being somebody close to your own children's age or you identify them as being like your mother or your partner and so sometimes that can make things a bit harder.

00:40:13.940 --> 00:40:25.750
We try and teach insight into what's happening so that you can identify it yourself and so that you don't actually cause harm to families or harm to yourself.

00:40:25.829 --> 00:40:31.849
When there's something difficult happening at home, many of our workers find it's harder to work in this area.

00:40:32.530 --> 00:40:40.429
Some people explicitly prefer to work part time, but I've always worked full time and I thrive on the work that I do.

00:40:41.168 --> 00:40:43.199
And I think it's important.

00:40:43.690 --> 00:40:57.389
To have trusted friends, if you can have a partner who supports you and accepts you, the, the, well, the literature shows that that makes for longevity in medical practice.

00:40:57.460 --> 00:41:07.699
I think that, uh, as you said, for me, music is a really important part of my life, and that gives me a, using a different part of my brain, really, and you can switch off.

00:41:08.280 --> 00:41:09.269
What's going on?

00:41:09.400 --> 00:41:14.650
For many, sport or exercise, walking around the block are really useful things as well.

00:41:15.130 --> 00:41:17.280
Having a variety of tasks.

00:41:17.699 --> 00:41:23.139
And I suppose as a senior doctor, I have a bit more control over my day to day life.

00:41:23.730 --> 00:41:36.480
In my early career, I was very focused on clinical work and I still undertake a large amount of clinical work, but I have teaching responsibilities, I have research, I have some administrative responsibilities.

00:41:37.139 --> 00:41:40.820
I'm supervising advanced trainees and junior doctors.

00:41:41.469 --> 00:41:46.829
And all of that gives variety and makes it easier to work in the area as well.

00:41:47.309 --> 00:42:00.579
What we don't want, uh, some of the destructive behaviours that we know, particularly doctors, are at risk of, and that's depression, suicide, alcoholism, and other destructive behaviours.

00:42:00.690 --> 00:42:05.320
And it can be very hard, but I suppose explicit focusing on self care is important.

00:42:05.914 --> 00:42:14.324
There's been a lot of talk within our circles about formal supervision and not many of my colleagues undertake that regularly.

00:42:14.974 --> 00:42:24.034
I've certainly sought support from a counsellor, um, organisational psychologist when I first had a leadership role.

00:42:24.610 --> 00:42:33.920
in palliative care to help me understand the dynamics of what was happening within the team, to understand my reactions and what my choices might be.

00:42:34.690 --> 00:42:46.300
We know that if doctors have good communication training that they are more likely to have positive outcomes in terms of their mental well being as well.

00:42:47.019 --> 00:42:52.519
So I think it's important that we have communication training in our programs of education.

00:42:52.579 --> 00:42:56.260
That's why I'm so passionate about communication in our medical program.

00:42:56.889 --> 00:43:14.735
But also we need to teach people to understand what's happening around them, to understand their own personality, understand their vulnerabilities and their strengths, and help see other people's vulnerabilities and They can support them in a team.

00:43:15.934 --> 00:43:24.195
Progressing from there, what are your thoughts on the scenario where you might be giving a patient bad news and you find that it becomes quite emotional when you almost break down yourself?

00:43:24.195 --> 00:43:26.485
Is this something that should be avoided or is it occasionally

00:43:26.485 --> 00:43:27.065
okay?

00:43:27.375 --> 00:43:28.795
What a great question, Gavin.

00:43:28.905 --> 00:43:35.885
Tears are natural, tears are normal, and they're not dangerous, usually, is how I would say it.

00:43:36.465 --> 00:43:46.565
And so, It would be wrong to think that I have no emotions for the situations that I'm in, but it's not like I'm right in the midst of it.

00:43:46.574 --> 00:44:01.414
I'm not one of those family members and if I start getting so emotional that I'm not able to function and not able to be objective and help support the people around you, then that's a warning signal for me that something's wrong.

00:44:02.224 --> 00:44:15.510
But it would be equally Terrible if I didn't actually have human emotions to see when things are sad, or they are not fair, or they seem out of the proper order of how things should unfold.

00:44:16.268 --> 00:44:18.059
And so tears in themselves.

00:44:18.775 --> 00:44:22.215
I think often help support our families.

00:44:22.235 --> 00:44:24.114
I wouldn't go out of my way to cry.

00:44:24.155 --> 00:44:27.594
I don't cry very often, but it's not unknown.

00:44:27.994 --> 00:44:33.695
But it's important that we understand that the emotion is a response to what's happening.

00:44:34.213 --> 00:44:40.954
It's not that we're actually gaining benefit ourselves by this emotional journey, if you like.

00:44:41.043 --> 00:44:46.193
So it's a bit like touch as well, you know, should you touch patients?

00:44:46.563 --> 00:44:56.110
Well, I'm cautious, but if somebody wants to hug me, then I will allow myself to be hugged, but I wouldn't initiate it.

00:44:56.309 --> 00:45:01.568
So I think that tears and emotion, I think it helps to say, I feel really upset about this.

00:45:01.590 --> 00:45:06.608
It's one of the steps in giving good, you know, of breaking bad news.

00:45:07.394 --> 00:45:17.094
is that you want to check how the person is feeling about it, but I think it's all right for us to say, look, I feel really distressed about this, telling you this information.

00:45:17.795 --> 00:45:20.144
And so why wouldn't you cry sometimes?

00:45:20.570 --> 00:45:20.769
It's

00:45:20.769 --> 00:45:26.739
likely for us in orthopaedics, it's not common that we have to give bad news, but certainly it's something we need to be prepared

00:45:26.739 --> 00:45:27.130
for.

00:45:27.539 --> 00:45:45.420
Yeah, and I think that all doctors will care for people who are facing death, whether they're part of the active treating team or they're treating other conditions, but we all need to understand the dynamics and have the words to be appropriate.

00:45:46.070 --> 00:45:51.329
and not sound false or but equally connect as human beings one to the other.

00:45:51.739 --> 00:45:52.079
Well, that's

00:45:52.090 --> 00:45:52.469
brilliant.

00:45:52.510 --> 00:45:55.349
It's been fantastic having a chat and talking about palliative medicine.

00:45:55.349 --> 00:45:57.699
I really appreciate your time you put forward to this, Greg.

00:45:58.190 --> 00:46:03.179
Perhaps the last take home point of a young GP or Medical student finishing their training.

00:46:03.440 --> 00:46:06.130
What would you say would be a take home point about palliative medicine?

00:46:06.639 --> 00:46:07.159
Well, thank

00:46:07.159 --> 00:46:13.139
you for the opportunity for, as you put it, improving the public relationship view of palliative medicine.

00:46:14.019 --> 00:46:21.958
I think that we believe firmly that every doctor needs to understand and learn about symptom control and our philosophy.

00:46:22.028 --> 00:46:24.719
But it's something that you need to keep practicing.

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Greg Crawford

Prof

Professor Greg Crawford AM is a practicing palliative medicine physician and was awarded a pHD 2008. His thesis was “Depression in palliative care in Australia.”
Prof Crawford teaches at the University of Adelaide, co-ordinating palliative care, pain management and symptom management.

He also provides tutorials in the Master of Clinical and Health Psychology, and Master of Counselling and Psychotherapy.

He has a long-standing interest in professionalism particularly as it relates to medical education.
Prof Crawford's major research activities are into the psychological issues for people and their carers, as the end of life approaches, as well as clinicians. He has particular interest in not only end-stage cancer, but also the issues for people with non-malignant disease.

Amongst many accolades, he has been recognised by University of Adelaide Executive Dean’s medal, Vice Chancellors award, the John Sands medal from RACP and was appointed as a Member in the Order of Australia in 2022 for his contribution to palliative medicine and tertiary education.

Unlocking the Secrets of Palliative Medicine

Greg Crawford

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