Primary Care - Respond to Deterioration
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Respond to Deterioration

Recognising and responding to patient deterioration is important to ensure the appropriate care is being delivered. Clinical tools such as the SPICTTM tool can be useful to support clinicians to recognise change in clinical condition. Prompts for this to be completed could be on request of the patient or family member. at agreed milestones, such as 75+ health assessments or chronic disease assessments, at regular time intervals (6 monthly, annually, etc.), or on recognition of a change in condition, function or capacity.

Signs of deterioration may include symptoms such as declining function, increasing fatigue, declining or fluctuating oral intake, declining or fluctuating conscious state, increasing pain, etc.

It is important to recognise when deterioration is most likely due to untreatable causes, such as disease progression, or when the possible treatments are not wanted, or are burdensome and inappropriate.

Practice Points
  • Explain to the patient and family/carer/substitute decision-maker.
  • Review the care needs and goals of care.
  • Review the advance care plan.
  • Implement palliative care plan or pathway, managing symptoms appropriately.
  • Review all medications.
  • Withdraw treatments, activities, medications that are no longer appropriate or benefitting the patient.
  • If some active treatment is still requested, choose the least burdensome options offered as a time-limited therapeutic trial e.g. 'if this trial of X does not help them stay more awake and active during the day, we will stop it in a few days'.
  • Be aware that continuing chemotherapy is generally not safe or clinically effective in a deteriorating patient who has become bed-bound.
  • Communicate with the treating team/s about the change in condition.
  • Consider holding a case conference if appropriate or necessary.
  • Consider deactivation of implantable cardioverter-defibrillator (AICD) devices to prevent delivery of shocks to a dying patient (PCA, 2018).

Patients will experience different illness trajectories depending on the primary diagnosis and presence of other diseases (co-morbidities). Palliative Care Australia identifies that there are three common trajectories of illness for people with a life-limiting illness:

  1. Short period of evident decline—these clients may have good function for a long period followed by a few weeks or months of rapid decline prior to death.
  2. Long-term limitations with intermittent serious episodes—these clients will have gradual decline in function. During each acute episode, the client is at risk of dying but they may not. However, function will continue to decline.
  3. Prolonged dwindling—the client has a long-term progressive disability and reduction in function. Death may be caused by infections, falls or fractures.

Across all of these illness trajectories it is important to identify and respond appropriately to deterioration of the patient caused by their primary diagnosis or as a result of other or confounding co-morbidities or events. It is also necessary to distinguish between deterioration that is due to irreversible causes, such as disease progression, versus onset of symptoms or disease that is reversible in nature, including medical emergencies. Appropriate clinical assessment, including consultation with the patient’s care team where necessary, or external experts such as specialist palliative care services is critical.

Palliative Care Australia (PCA) 2018, Palliative Care Service Development Guidelines, Palliative Care Australia, Sydney.

Supportive and Palliative Care Indicators Tool (SPICTTM)
The University of Edinburgh/NHS Lothian
The SPICTTM helps professionals identify people with general indicators of poor or deteriorating health and clinical signs of life-limiting conditions for assessment and care planning. The SPICTTM tool is free to download, but the developers of the tool ask that you provide your details prior to download so they can keep you informed of SPICTTM updates and relevant SPICTTM news.

 
Guideline to using SPICTTM in the community (392kb pdf)
The University of Edinburgh
This is a guide to support professionals using the SPICTTM tool in the community.
 
Implantable Cardioverter-Defibrillators at End of Life
Palliative Care Network of Wisconsin
This factsheet provides information on implantable cardioverter-defibrillators at the end of life.
 
Cardiac Pacemakers at the End of Life
Palliative Care Network of Wisconsin
This factsheet provides information on pacemakers and deactivation at end of life.
Podcast Episode 1: Recognise Death
Royal Australian College of Physicians (RACP)
This episode features interviews with Dr Amanda Walker, Dr Charlie Corke and Dr Peter Saul discussing recognising dying and discussing dying with patients, families and carers.
 
Withholding and withdrawing life-sustaining medical treatment
End of Life Directions in Aged Care (ELDAC)
This factsheet provides information on responsibilities around withholding and withdrawing life-sustaining medical treatment.

Page updated 23 August 2018