AAHPM Winter Quarterly 2011 : Page 13WINTER 2011 13 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 advanta-geous device to which every hospital and community nurse has access. A syringe driver makes all the differ-ence in maintaining comfort when dealing with relatively refractory symptoms, no matter the setting: home, nurs-ing 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 vari-ety 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 con-tents over 24 hours, or with stable symptom relief on a 48-hour fill cycle. The commonly used drugs for subcu-taneous 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 ben-zodiazepine for subcutaneous use. Ketamine is not infre-quently added in certain cases; every palliative medicine specialist is familiar with Ketamine dosing. In our home-based 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 compe-tent 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 The ubiquitous syringe driver (above) 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 dur-ing 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 “Texan-tipodes,” a blog about a Texan Down Under, available at http://dennis.pacl.info. References 1. Newsweek . Interactive infographic of the world’s best countries. www.newsweek.com/2010/08/15/interactive-infographic-of-the-worlds-best-countries.html. Accessed October 27, 2011. 2. Davis K, Schoen C, Stremikis K. Mirror, mirror on the wall. How the performance of the U.S. health care system compares internationally. 2010 update. The Commonwealth Fund. www. commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010. pdf. Accessed October 27, 2011. 3. Australian Government Department of Health and Ageing. Working in private practice. www.health.gov.au/internet/otd/ publishing.nsf/Content/workingInPrivatePractice. Accessed October 26, 2011. Dennis Pacl, MD FAAP FACP, is medical director at Extracare Palliative Consultants PA in Bentonville, AR. He can be reached at dspacl@pol.net. VOL. 12 Publication List Using a screen reader? Click Here |
