Is 'Acute Palliative Care' an Oxymoron?

Palliative care is a medical specialty that has gained prominence in Singapore due to the projected shift to a super-aged society by 2026. Advanced age is linked to more illnesses, poorer health status, and a higher risk of death. As older adults embrace the evening of life, they often prioritise quality of life over quantity of life. This is where palliative care plays a crucial role, aiming to enhance the quality of life for patients and their families facing challenges associated with life-threatening illnesses, through early identification and treatment of physical, psychological, social, and spiritual symptoms.

Many assume that palliative patients, who prioritise comfort over life-prolonging measures, do not need acute care in the hospital. However, despite receiving palliative care, some of these patients may benefit from emergent acute care. There are now three palliative care units in restructured hospitals that can provide appropriate acute care, including Tan Tock Seng Hospital.

Understanding the complexity

I’ve come across a few memorable cases during my practice where acute intervention helped maintain a good quality of life and even prolonged survival for these patients considered to be at the end of life. (All names have been changed.)

Mr Chua, an 88-year-old patient, suffered from advanced bladder cancer with persistent, severe bleeding in the urine despite various treatments such as surgery, chemotherapy, and radiotherapy. He needed hospital admission every two weeks for blood transfusions due to breathlessness and weakness from low blood counts. Following the transfusions, he found joy in walking in his garden and spending time with his grandchildren.

Our team was consulted to assess Mr Chua, considering his end-of-life status with uncontrollable bleeding, to discuss discontinuing further transfusions. During our conversation, Mr Chua accepted his condition and the possibility of his eventual passing if no other interventions were available. At the same time, we consulted with Mr Chua's bladder surgeon regarding the option of additional bladder scopes and partial cancer resection. Fortunately, the option was available and the bleeding ceased after those procedures, allowing Mr Chua to continue his lifestyle and avoid the frequent transfusions for the next six months.

Mr Raman, a 64-year-old patient, suffered from liver cancer and severe pain caused by bleeding within the cancer. He had previously declined treatment for liver cancer out of concern for burdening his family. He preferred to be kept comfortable and to pass away naturally. His pain was challenging to manage, so we arranged a surgery under local anesthesia to implant a device into his spine (intra-thecal) for delivering pain medication.

Ahead of the procedure, we had to discuss with him the possibility of active cardiopulmonary resuscitation in case he experienced complications from the procedure – when initially diagnosed with cancer, he had expressed that he wanted to refuse resuscitation. Fortunately, the procedure was successful, and his pain was effectively managed with the intra-thecal device.

There are also cases where patients choose options that will change the trajectory of their care, but we always respect their wishes and deliver the best care we can, regardless of outcome. Mdm Lee, a 70-year-old patient, was battling stage 4 breast cancer that had spread to the bones while undergoing hormonal treatment. She experienced a fracture in her right hip bone and was advised to undergo surgery, but she chose to decline due to personal reasons.

Her care requirements increased as she needed help with daily activities due to the pain in her right hip, and she received supportive treatment with injectable medications. Being single without any family support, she faced challenges in managing her condition and eventually succumbed to complications arising from being bedridden, passing away within a month of her admission.

Guiding care and advocating for patients

From these cases, we observe the various aspects of acute palliative care in action. In all three instances, we can simply provide additional medications to ensure their comfort. However, since the aim of palliative care is to uphold quality of life, we should take further steps when necessary. In Mr Chua's and potentially Mdm Lee’s cases, the suggested interventions can address cancer-related complications, preserve mobility, and even extend life. For Mr Raman and possibly Mdm Lee, the recommended interventions can aid in ensuring comfort. For Mr Chua and Mr Raman, undergoing the procedure also involves accepting a higher risk of complications, necessitating sensitive, balanced, and respectful communication to enable them to make an informed decision based on their personal objectives and values.

In these scenarios, our role in acute palliative care is to offer guidance based on the prognosis of the underlying illness, the risks and benefits outlined by the surgical team, while considering the patient's preferences and anticipated quality of life.

In essence, acute palliative care plays a crucial role in the current palliative care landscape by providing access to specialised interventions (not limited to the examples) that can aid in symptom management. This is not just the domain of the medical or nursing team; our allied health colleagues play a crucial role as part of the multidisciplinary care team for symptom management in all facets including physical, psychological, social and spiritual domains.

The decision-making process for these specialised interventions necessitates a care team with expertise in many different aspects: i. estimating survival across a wide range of diseases, ii. extensive knowledge of the efficacy of medications for symptom control and the appropriateness of interventions, iii. a compassionate, empathetic and humanistic approach to communication, and iv. the determination to advocate, coordinate, and establish a path towards comfort for patients during their most vulnerable moments.

Acute palliative care outside the hospital

In response to Singapore’s demographic changes, our national initiative HealthierSG emphasises care in the community, and the future of palliative care similarly entails the integration of acute palliative care into the community. For example, with the right resources in place, patients would be able to liaise with intervention specialists or surgeons, go through the complex decision-making process, and receive post-procedure monitoring and recovery care, all under the care of inpatient hospice or home palliative teams. This approach will allow patients with terminal illnesses, who will not benefit from further disease-modifying treatment, to stay in the comfort of their home or a specialised hospice setting, and spend quality time with loved ones towards the end of life.

This article is written by Dr Goh Wen Yang, a consultant in geriatric and palliative medicine in Tan Tock Seng Hospital. He has special interest in caring for older adults with end stage organ diseases, cancer and multiple diseases towards the end of life.