AAHPM — Winter Quarterly 2011
Palliative Care Adventures in Oz
A display jumped out at me in the exhibit hall of AAHPM & HPNA’s Annual Assembly in Salt Lake City, UT, in February 2007. The background displayed the Australian National Capital during Floriade, a spring floral festival held in Canberra, Australia. The display read, “Practice Palliative Care in Canberra.” At the time, I was feeling fed up with the hassles of private practice: credentialing, billing, collecting from insurance companies, and working 60-plus hours per week. I loved my work, but my family was suffering as a result of a poor work-life balance. I wanted to inject a little adventure into our lives and have the time to enjoy it. I gave the recruiter my card that day, and the rest is a delightful memory.
The Aussies rank highly amongst G-20 countries in terms of health, education, economy, and politics, ranking fourth overall compared with the United States, which ranked 11th in 2010.1 According to a Commonwealth Fund report that compares seven Western countries, Australia ranks in the top five for seven out of eleven measures of healthcare quality; the United States is ranked in the top five for only one quality outcome measure.2 For the most important measure—long, healthy, and productive lives— Australia comes in first, while the United States is last on the list. My intention here is not to speak negatively about the United States but rather to make the point that Australia is a good place to live and work.
In many ways the genesis of palliative medicine in Australia is similar to that of the United States—founded on the principles espoused by Cicely Saunders, Balfour Mount, Neil McDonald, Irene Higginson, and other icons of our specialty. The specialty received formal recognition in 2007 from the Royal Australasian College of Physicians (RACP), the certifying authority for medical specialties.
What’s enjoyably different in Australia is that palliative care is well integrated into the healthcare system, and more importantly, adequately funded relative to other specialties. Because Australia is a member nation of the British Commonwealth, health care more closely resembles the UK model. Hospice is a place you go to receive inpatient palliative care. Anyone is eligible for palliative care, independent of any “active treatment” they are receiving. There is an extensive network of home-based palliative care services, even in rural areas, where community nurses receive specialized training to serve as clinical nurse specialists (CNSs) who will care for patients and advise general practitioners (GPs) on pain and symptom management. They also will make recommendations regarding referral of home-based patients for specialist-level consultation or treatment.
I received many phone calls from community nurses. Often, adjustments could be made to a medication regimen or I could arrange to see the patient in clinic; on occasion, a transfer to hospice was necessary. All of the “base hospitals” (small community hospitals with 20 to 50 beds) in outlying towns and rural service areas have beds set aside for palliative care admissions. Thus, I would receive the occasional phone call from a GP or CNS about their inpatients as well.
Most specialists practice in a regional referral center, and consequently many of the home-based patients can be evaluated in clinic or when they are visiting other specialists. The oncology clinic, for example, was happy to have me visit a patient while they were infusing chemotherapy. The advantage of seeing patients in another specialty clinic is the collegial aspect of being able to confer in real time with other specialists. Good communication with treating doctors is part of the culture. Every doctor, including the GP, would send a doctor’s letter if they were referring a patient or following up with someone for whom I, too, was caring. The doctor’s letter would contain an interval history (or complete history if it was a new patient) and what treatment they were receiving.
It was a common occurrence to get a phone call from another specialist while they were seeing a patient in clinic to coordinate treatment or follow-up.
When it comes to complex symptom management, we can learn a lot from our Commonwealth colleagues, such as use of the ubiquitous syringe driver, a most advantageous device to which every hospital and community nurse has access. A syringe driver makes all the difference in maintaining comfort when dealing with relatively refractory symptoms, no matter the setting: home, nursing home, hospice or hospital. I can’t begin to say how many admissions or readmissions were prevented by one of these little devices. The real beauty of it is nurses in almost every setting have experience in setting one up and making ordered changes to the dosage.
There are well-established compatibilities of a variety of medications that can be mixed and individually titrated for specific symptom control by adjusting the components within the admixture, based on the clinical response. Changes to the admixture are usually made on a daily basis. The driver is set to inject the syringe contents over 24 hours, or with stable symptom relief on a 48-hour fill cycle. The commonly used drugs for subcutaneous administration are familiar, but there are some exceptions such as cyclizine or levomepromazine (ie, methotrimeprazine, Nozinan) for nausea. Morphine is the standard analgesic, and midazolam is the standard benzodiazepine for subcutaneous use. Ketamine is not infrequently added in certain cases; every palliative medicine specialist is familiar with Ketamine dosing. In our homebased service of more than 200 patients, there would be fewer than five patients on average who required syringe driver dosing of medications; most often they were in the imminent stage of their disease process.
One reason I think the Australian system works so well is the role played by the GP in healthcare delivery. These doctors are the linchpins of an efficient system. Almost all of the GPs I worked with were reasonably competent in primary palliative care, and many did home visits when necessary. The vast majority of doctors in Australia are self-employed and in private practice.3 Why is solo practice alive and well in Australia? It’s simple: There is no hassle! Physicians don’t need three employees to handle contracts, obtain prior authorizations, and code and bill. Everyone has Medicare, and many patients also have a private cover policy, a commercial policy from a private insurer. Because the private plans compete with Medicare, costs are much lower. Australians spend about 7% of their gross domestic product on health care. Dual healthcare coverage is promoted by a 1% Medicare levy on federal income taxes for those who have incomes in excess of $160,000 per year, but you can be exempted from the levy by purchasing private cover. Private cover for my family of five was substantially less than what I pay in the United States.
Eight months after that fateful Annual Assembly in Salt Lake City, I had a work visa in my hand and approval from the RACP to practice as a senior staff consultant in palliative medicine. Although it wasn’t easy to make all the arrangements, I can emphatically state that neither I nor my family was disappointed for a single second during our 2-year adventure in Australia. I like to think the reason health care in Australia is so efficient is at least in part because palliative care works so well there. You can read more about the adventures we enjoyed at “Texantipodes,” a blog about a Texan Down Under, available at http://dennis.pacl.info.