Medical Forum – November 2020 – Public Edition

Safe keeping ARE WE DOING OUR BEST?

Aged & Palliative Care issue | Holistic dying, stroke, falls, aged care plans, cardiac innovations

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EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

It’s time! It is clear that a fundamental overhaul of the design, objectives, regulation and funding of aged care in Australia is required – not merely patching up. The Royal Commission is committed to systemic reform. Richard Tracey and Lynelle Briggs, Royal Commissioner into Aged Care Quality and Safety

The Royal Commission’s final report is not going to be pretty reading for anyone who cares for our elderly citizens. You don’t have to go any further than the cover of the commissioners’ interim report to get an idea of where they are going. Neglect is the title and the content unpicks how the aged care system, so poorly managed for years by our political masters, has failed to meet the needs of our older citizens in the delivery of safe and quality care. That is not to say there are not quality providers of residential aged care. There are and they are numerous. But they struggle to balance the high-care needs of their residents with the everchanging, ideological push and pull of government. The federal government and, to a lesser extent, state governments, need to own up to these shocking policy and regulation shortfalls and clean up their game before they start cleaning up anyone else’s. Let’s start with a commitment to adequate funding and workforce reform so that the reality can start living up to a shadow of their rhetoric of a well-trained, motivated aged care sector. Since 1997, there has been 18 major public reports and inquiries related to public-funded aged care in Australia. Each of them executed in good faith by inquirers who wanted to make a positive difference – yes, politicians are among them. Each of those 18 reports offered sound direction. Eighteen of them have been ignored, except when it’s time for politicians to call for another inquiry when the heat starts cranking up in the voter kitchen. We are an ageing community. The pandemic has exacerbated that worrying fact. We, who are writing and reading this, will be recipients of this lack of political courage – if we’re lucky to be young enough, we just may benefit from decisive action after November 20 when the final report of the Royal Commission is tabled in Parliament. The commissioners say the report will recommend comprehensive reform and major transformation of the aged care system in Australia. “We will chart a new direction for the sector, bringing a clear sense of purpose and of quality, and a renewed focus on compassion and kindness.” Hope springs eternal.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

MEDICAL FORUM | AGED & PALLIATIVE CARE ISSUE

NOVEMBER 2020 | 1

CONTENTS | NOVEMBER 2020 – AGED & PALLIATIVE CARE ISSUE

Inside this issue 14

30 18 20

FEATURES

NEWS & VIEWS

14 Close-Up: Dr Sarah Cherian 18 Q&A: Dr Gemma Hounslow 20 Aged Care in the COVID era

1

Readiness of residential aged care

10 In the news 11 In brief 24 Aged Care:

30 Working in Palliative Care – Dr Jonathan Ramachenderan

Editorial: It’s Time – Jan Hallam

28 The aged care workforce 35 Holistic dying 53 Wine review: Chateau Tanunda – Dr Martin Buck

a GP perspectives

25 Advanced care planning

Doctors Dozen... Dr Moira Westmore is the winner of the September Schild Estate Doctors Dozen For your chance to win a dozen wines from Chateau Tanunda, see the review on Page 53 and go to the website to enter. www.mforum.com.au (click on the competitions tab)

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MEDICAL FORUM | AGED & PALLIATIVE CARE ISSUE

CONTENTS

PUBLISHERS Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

Clinicals

ADVERTISING Advertising Manager Andrew Bowyer (0403 282 510) andrew@mforum.com.au

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Clinical utility of outpatient troponin Dr Aaron Simpson

41

Testosterone & type 2 diabetes Prof Bu B. Yeap

46

Falls prevention in the elderly Dr Joon Qing (Jason) Tan

47

Radiation therapy and heart disease Dr Benjamin King & Dr Tee Lim

49

RG-007 (R18) in ischaemic stroke Dr David Blacker

50

Low haemoglobin in the elderly Dr Benedict Carnley

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au

43

Colchicine & chronic coronary disease Prof Peter Thompson & Dr Mark Nidorf

Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

51

Goals of Patient Care Dr Kevin Yuen

39

Health and ageing Dr Joe Kosterich

Guest Columns

CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au www.mforum.com.au

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Private health insurance and competition David McMullen

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Mental Health and Step-parenting Karalee Katsambanis

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Private health insurance and competition Special counsel David McMullen explores the subtleties of 'no gap' health insurance deals and the impact on competition. Private health insurance is critically important to Australia’s two-tiered health system and, yet, private health cover is reportedly in a so-called ‘death spiral’ with mass desertion of young healthy people because of the increasing cost of cover. Those who are left are more likely to need health care, which drives insurance premiums up. Criticism isn’t just coming from the consumer. Some in the health sector often complain about the various private health funds and their ‘preferred provider’ schemes. Common features of these schemes may include: • higher rebates for visits to preferred providers compared to those for non-participating providers; • reimbursement only for visits to preferred providers; • requirements for preferred providers not to charge above pricing set by the health fund; • free visits/check-ups to preferred providers only. Criticisms of preferred provider schemes vary. Some label the arrangements unfair, an intrusion on professional and clinical practice, a misuse of market power and/or anti-competitive. So what effect are private health funds having on competition, and why hasn’t the regulator put this to an end?

Regulating competition The Competition and Consumer Act 2010 (Cth) (Act) is Commonwealth legislation that aims to promote competition and fair trading, and protect consumers. The Act has

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a wide reach, impacting almost every aspect of business activity in Australia. It is administered and enforced by the Australian Competition and Consumer Commission (ACCC). Amongst other things, the Act prohibits certain anti-competitive conduct so that both consumers and businesses enjoy the benefits of a competitive, efficient economy. There are some key concepts for present purposes: • Anti-competitive conduct is, broadly speaking, conduct which can reduce the level of competition between businesses. • The Act generally prohibits contracts, arrangements, understandings or concerted practices that have ‘the purpose, or would have or be likely to have the effect, of substantially lessening competition’. • Exclusive dealing, is conduct which may occur when a party imposes restrictions on another party’s freedom to choose with whom they do business, and in what manner. The practice of exclusive dealing is prohibited where it ‘has the purpose,

or has or is likely to have the effect, of substantially lessening competition’. • Third line forcing is a type of exclusive dealing. It is third line forcing to supply goods/ services (or to supply them at a particular price or with ‘a discount, allowance, rebate or credit’) on the condition that the purchaser acquires the goods/ services from a particular third party. It is also third line forcing to refuse a supply because the purchaser will not agree to such a condition. Before November 2017, third line forcing was strictly illegal under the Act, but the Act has since been amended. Like other exclusive dealing, it is now permissible so long as it does not substantially lessen competition. What would constitute a ‘substantial lessening’ of competition? This depends on a range of circumstances, including (in the case of private health funds): • the particular insurer and their market share; continued on Page 6

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Clinical utility of outpatient troponin Cardiac troponin I and T are well known as biomarkers in the assessment of myocardial injury. An appreciation and understanding the pathophysiology of troponin and the timing of troponin testing is fundamental in the clinical utility of these biomarkers, as troponin and its kinetics are central to the universal definition of acute myocardial infarction (AMI). Troponin levels become elevated in serum within hours of an AMI, remaining elevated for up to 7-10 days. There are other conditions that result in elevated troponin concentrations, so it is essential that the results of troponin tests are interpreted in conjunction with clinical findings and electrocardiography results. The dynamics of troponin levels help distinguish AMI from non-AMI conditions, thus serial troponin testing is a well-documented approach in the assessment of patients with suspected acute coronary syndrome (ACS). Troponin testing within the community is complex with ACS management guidelines recommending a troponin test result be available within 60 minutes of blood being drawn or point-of-care testing be available if the former is difficult. Appreciably this is difficult for large pathology networks that test hundreds of community samples daily involving a large number of collection centres and clinical practices. The clinical utility of troponin in an outpatient setting is best reserved for low-risk patients and may occur in two situations. The first is when a patient has had symptoms of ACS in the preceding days but, on presentation,

symptoms have resolved and the patient is clinically stable and deemed to be at low risk. The second is when the patient presents with atypical symptoms with a low likelihood of ACS, and the clinician uses troponin testing to ‘rule out’ ACS. An elevated troponin in this setting may occasionally be detected, which will subsequently allow for appropriate management and specialist referral. Ordering a troponin test in the community setting should be done cautiously. It is not appropriate to measure serial troponin levels in the community, as the patient will not be monitored for possible worsening symptoms and potential complications. It is also not recommended to measure troponin in asymptomatic patients or to use troponin as a screening tool as the result may be problematic, with no clear management strategy, and may lead to further unnecessary investigations. If a troponin test is ordered in an outpatient setting, it should be clearly marked as urgent and a mechanism in place for the doctor and patient to be contacted with the results. If such logistics are not in place, potential delays with followup of positive results may occur. The patient could potentially be in the community with an elevated troponin level without adequate follow-up and not be receiving appropriate clinical care. If there is a lack of capacity to receive troponin results and arrange appropriate clinical follow-up when performed in the community on low-risk patients (e.g. afternoon, weekends), referral to an emergency department would be considered appropriate. It is acceptable clinical practice to

Dr Aaron Simpson Head of Biochemistry

About the Author Aaron gained his MBBS at the University of Sydney and proceeded to complete fellowships in both Chemical Pathology and Endocrinology. He has been widely published in both disciplines with particular interests in endocrine hypertension, adrenal, pituitary, and calcium metabolism disorders. Aaron is Clinipath Pathology’s Head of Biochemistry.

promptly refer patients presenting with symptoms suggestive of ACS to hospital without first undertaking community troponin testing. As with any request, referral for acute management should not be delayed until receipt of the troponin result, as any delay may significantly negatively impact on outcomes and result in increased morbidity and mortality.

Conclusion Clinicians should have a high threshold for requesting troponin testing in the outpatient setting, carefully assessing and evaluating the risk before ordering. Positive troponin test results usually change the course of management, but the time frame in which the result becomes available must be balanced against the risk of delay in diagnosis and therapy. A troponin test should not be requested unless a Clinician is confident a robust process is in place by which they can be contacted, day or night in the case of a positive result. References on request

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

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Private health insurance and competition continued from Page 4 • details of the ‘preferred provider’ scheme; • the size and nature of the market; • whether activities have an important or a large effect on the market; • substitutes or alternatives that are available (or not available) to consumers. In contrast, damage to an individual’s business would not be sufficient to satisfy the ‘substantial lessening of competition’ test. Assessing impact on competition requires economic analysis. This can be complex in a health setting, particularly because decision making by patients and providers is affected by a range of factors – including clinical factors – and is not solely based on pricing or economics.

Competing perspectives Funds’ perspective To the extent it is possible to distil the position advanced by the private health funds, it would be that preferred provider arrangements either do not substantially lessen competition, or actually enhance competition. Some of the main reasoning includes: 1. Consumers are free to exercise choice and find the best plans and providers to suit their needs. 2. Patients are not ‘forced’ to acquire services from any particular provider. Higher rebates are simply paid as a consequence of a ‘voluntary’ choice being made. 3. Providers who meet a fund’s recognition criteria can apply to participate in a preferred provider scheme, and can opt out at any time. 4. A guarantee of no-gap or a low-fixed gap is of substantial net benefit to fund members and the community as a whole. 5. Preferred provider schemes foster competition among providers and between funds. i.e., the preferred providers of a given fund will compete against each other, as well as competing against the preferred providers of other funds. 6 | NOVEMBER 2020

6. Market competition increases and customer outcomes are improved through: a. improved consumer understanding and ease of comparison of private health insurance products; b. increased transparency; c. reduced cost of growth for small- and medium sized funds; d. a more prominent consumer ‘voice’; e. portability provisions – ensuring no new waiting periods or exclusions when changing policies; f. consumer control and choice in providers, hospitals and timing of health procedures. Industry perspectives Not surprisingly, many health professionals and industry bodies take a very different view to that of health funds. The argument is that health funds in essence choose who will provide services, and on what conditions. This limits competition between providers. Some of the main complaints are: 1. Preferred provider arrangements discourage patients from using their own providers of choice, and therefore inherently lessen competition. 2. Health fund advertising promotes preferred providers above others, which creates an uneven field of competition and is disadvantageous to practitioners who choose not to participate. 3. Differential rebates lessen competition by disadvantaging patients if they choose a provider who is not ‘preferred’ by their fund. 4. The lack of uniformity (between preferred and non-preferred providers) on rebates per service, annual limits etc. lessens competition because it is impossible to directly compare coverage. 5. Using terms such as ‘preferred’ provider implies that a nonpreferred provider is somehow inferior. 6. Health funds are privy to commercially sensitive information, which they can use to their advantage and to the detriment of providers.

ACCC stance The ACCC has considered the practices of private health funds on various occasions. In summary, the position has been: 1. Health funds can have sound commercial reasons for the selection of contracted providers, without necessarily having an unlawful anti-competitive purpose. 2. Preferred provider arrangements with health care service providers can deliver benefits to health fund members in the form of higher and more predictable rebates. 3. In general, businesses decide for themselves who they wish to deal with. 4. Preferred provider arrangements could in some circumstances substantially lessen competition, and therefore contravene the Act. But the ACCC makes no general finding that preferred provider arrangements are anticompetitive, in contravention of the Act.

Conclusion Private health insurers will typically seek to grow their membership by keeping premiums as low as possible, and paying rebates that are as high as possible. How exactly they go about this will determine whether or not their conduct is anticompetitive – as opposed to merely unpalatable to providers. This is a complex area, and there may well be argument for reform to the way private health funds are regulated. Reforms may well translate to increased uptake of private health insurance in Australia. For now, it appears that this is an area that the regulator will continue to monitor, but preferred provider schemes are here to stay. ED: David McMullen is special counsel at Panetta McGrath Lawyers. This information is intended as a general overview and discussion. The information provided is not intended to be, and should not be used as, a substitute for taking legal advice in any specific information. Panetta McGrath is not responsible for any actions taken on the basis of this information.

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Step-by-step parenthood The highs and low of step-parenting can be tricky terrain to negotiate, writes Karalee Katsambanis.

Put five medical professionals in a room and they will undoubtedly come up with at least eight different opinions on how best to treat a patient. Put five stepparents in a room and they will also undoubtedly come up with at least eight different opinions for treating a problem. A medical professional can be guided objectively by their training and experience. But when it comes to step-parenting and blended families, parenting training does not exist and emotions are far more powerful than logic. Good medicine is not just about treating the condition, it is as much about treating the cause. Few realise the immense stress step parents are subjected to and their mental health is subsequently often underestimated. No one grows up dreaming of being a stepparent. Indeed, it is role that chooses you, rather than you choosing it. Fantastic that “love” has been found a second time around, but there is a hidden cost to mental health. The majority of stepparents choose to make a positive difference in the life of their stepchild. They do not sign up for the emotional or badmouthing games and in the worst cases the legal minefield they are often subjected to. They sign up not realising that establishing relationships with their stepchildren can sometimes take years rather than weeks or months. Do you have patients suffering from anxiety and/or depression? Have you asked them if they are a

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stepparent? It is a question worth considering.

underestimated and has never been more important.

Every stepfamily's situation is different, but there are two golden rules to remember: • There is no one right way to stepparent, but there is always one right way to behave in a stepfamily and that is with respect. • Your ex is your ex but will never be your children’s ex, so stop bad mouthing.

Parenting is not a competition. There is room for both stepparents and parents to play the most important role they will do in their lives.

Remember these two golden rules and you will be head and shoulders above the rest. Most people mean well. However, THE most annoying thing you can say to any stepparent, especially those enduring drama, is to say, ‘well, you knew what you signed up for’. The stepparent will shut down and never mention it again. Successful parenting does not just simply happen. Most of the wellmeaning advice you get about stepparenting and blended families comes from people who are not stepparents and who do not live in a blended family. It is a tough job at the best of times but helping to parent someone’s else child is a whole different ball game complete with challenges many biological parents simply do not realise. More often than not, stepparenting is about copping criticism rather than claiming credit.

Stepfamily and blended family life, even at its happiest, is still far more complex than most people can imagine. Stepchildren and biological children in the same home cannot be parented in exactly the same way. There will be different ages, personalities, needs and histories. It is not the stepparent’s job to ‘fix’ their stepchildren, but it is their job to do the best they can under the circumstances which ironically may be contributing to the erosion of their own personal mental health. So the next time someone comes to see you about their mental health, it may well actually be their own stepfamily that is the real cause. Please, ask your patients. ED: Karalee Katsambanis is a TV commentator, journalist, columnist and media trainer. She is a mother of three children and stepmother of two young adults. She has published a book, Step Parenting with Purpose – everything you wanted to know but were too afraid to ask. www.karaleekatsambanis.com

Read this story on mforum.com.au

The fundamental value of having good communication between the stepparents and biological parents – with everyone on the same page working together for the benefit of the children – cannot be

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OPINION

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Palliative Dementia Leading in-home health and aged care provider Silver Chain has launched a unique palliative care service to make the end stage of life for West Australians with dementia or a memory impairment easier. The Silver Chain Palliative Dementia Service is run by Nurse Practitioners Giuliana Duffy and Claire Doyle, who provide palliative care for dementia clients and those with other chronic end-of-life conditions. “This was set up to link in and support dementia and memory impairment clients at home,” Ms Doyle said. “We look at a variety of issues that may arise such as symptom management, communication styles, the clients’ environment and carers.” Working closely with general practitioners (GPs) and geriatricians, Ms Duffy and Ms Doyle bring a holistic approach to their clients. The pair has expertise and advanced qualifications in both palliative care and dementia. They are also able to review current medication and prescribe new medication if necessary as well as arrange any blood tests that may be required for clients in their homes. “Hospital avoidance is the main aim of the service, but if clients

T (08) 9242 0242

are admitted, we want to ensure family members understand decisions regarding advance care planning,” Ms Duffy said. “Having a clear care plan in place takes away some of the natural stressors, so both the client and the family can focus on what is most important to them.” Silver Chain client Sue is one of 460,000 Australians living with dementia. Her husband Doug is one of almost 1.6 million Australians involved in their care. “Sue was diagnosed with early onset dementia about two years ago at the age of 60,” Doug said. “I noticed she was starting to forget little things. I saw multiple doctors who all dismissed what I was saying, then one finally gave her the dementia diagnosis.” The couple has been supported by Silver Chain since Sue received a diagnosis of duodenum cancer earlier this year.

“Sue underwent a 10-hour operation to remove the cancer and spent five weeks in hospital. We were referred to Jiulie (Ms Duffy) by Sue’s GP. She checks in regularly and also filled in a form before Sue’s operation so the hospital knew what she liked and disliked.” Doug said while he was dedicated to his wife’s care, being her primary carer could be challenging at times. “We are together 24 hours a day, seven days a week,” he said. “It can get overwhelming. But thanks to Jiulie’s help navigating the National Disability Insurance Scheme (NDIS), Sue can meet with similar people once a week and I can have a break. Silver Chain’s support has been fabulous.” The service is available to clients who have moderately severe dementia – assessed by a functional assessment scale – as well as agree to the service themselves and be living at home.

W silverchain.org.au

A 6 Sundercombe Street, Osborne Park, WA, 6017 SilverChainGroup

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IN THE NEWS

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Vale Professor Michael Quinlan The medical community and, particularly, the St John of God and University of Notre Dame families are mourning the loss of Professor Michael Quinlan, who died recently. Prof Quinlan had a lifetime association with the Subiaco Hospital, in fact he was born there. When he continued the family tradition of studying medicine, it was to the St John of God Subiaco hospital where he commenced as a general physician in 1968 alongside appointments at SCGH and RPH. “He was a superb General Physician, his diagnostic skills being honed before the advent of today’s technology, Subiaco’s chief executive Professor Shirley Bowen said. “He lobbied for UWA medical students to receive teaching in a private hospital setting and was successful in bringing both UWA and eventually University of Notre Dame medical and nursing students to Subiaco. “This made Subiaco a teaching hospital and contributed to the high quality of care that we have today.” He was also one of the “founding fathers” of the University of Notre Dame Australia and the advent of the Notre Dame Medical School and a scholarship there bears his name. Prof Bowen said Prof Quinlan would long be remembered for his enduring contribution to teaching and the medical profession.

College fail It hasn’t been a great month for the RACGP with technical hitches prompting the abandonment of the Key Feature Problem exam and the Applied Knowledge Test and subsequent refunding fees to all candidates. The Acting President, Associate Professor Ayman Shenouda, apologised unreservedly and said the college aimed to deliver a rerun of the exams this year. A couple of days later the college announced it was suspending the Candidate Assessment and Applied Knowledge Test (CAAKT) for the final intake of the 2021 Australian General Practice Training (AGPT) program (with full refund). The reason was that it was to use the same platform as the ill-fated KFP exam. Prof Shenouda said the college had reached an agreement with Regional Training Organisations (RTOs) to allow all final intake candidates to progress through the selection process without delay. “Given the relatively small number of candidates for the second and 10 | NOVEMBER 2020

“Many of us have benefited from his wisdom and guidance. He was a wonderful teacher, mentor and colleague,” she said. “Put simply, Michael was a scholar and a gentleman. We are honoured by his enduring association with SJG Subiaco Hospital. His legacy of compassion and healing will live on in the generations of doctors he has taught and mentored.”

final AGPT intake for 2021, the RTOs have agreed all CAAKT candidates will automatically progress to the final selection process where their medical knowledge as well as their clinical, ethical and other decision-making skills will be tested at the multiple mini-interview,” he said. Counselling services were available through the GP Support Program and Drs4Drs for affected candidates.

Docs back plastic ban Doctors for the Environment WA are helping with the campaign to ban plastics to clean up our seas and waterways. It is combining with WA Seabird Rescue to host a free community screening of Albatross on Friday, November 6, at 6.15pm at the North Fremantle Community Hall. The documentary was made from 400 hours of footage filmed over four years on Midway Island in the North Pacific following these gentle giants of the sky, which are now listed as

endangered largely due to the effects of plastics in the ocean. There will be stalls and fundraisers as wells as a comment board to encourage the WA Premier to ban single-use plastics to bring the state in line with Queensland and South Australia. Bookings are essential. RSVP at https://www.facebook. com/events/760573911174825/ For information contact Dr Louise Sparrow louisesparrow@gmail.com

Hit on screening The impact of the COVID-19 pandemic has long been thought to have severely impacted routine cancer screening, in a similar way as it impacted on GP visits. A report by the AIHW now has quantified what was suspected. The report, Cancer screening and COVID-19 in Australia, looks at data from January to June 2020 on the three national cancer screening programs—BreastScreen Australia, the National Cervical Screening Program, and the National Bowel Cancer Screening Program.

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IN BRIEF The number of screening mammograms declined sharply with the service pausing in late March for a little less than a month. While more than 70,000 mammograms were performed in March 2020, this fell to around 1,100 in April. Overall, there were around 145,000 fewer screening mammograms conducted between January and June compared to the same time in 2018. The number of cervical screening tests was expected to drop in 2020 due to the National Cervical Screening Program changing from two-yearly to five-yearly screening. The AIHW said it wasn’t possible yet to know the impact of the pandemic on test rates. Data shows a decline in the number of cervical screening tests from the second half of March 2020, which remained low throughout April, during which fewer than 30,000 tests were carried out. The number of tests began to increase in May, and rose again in June. It is thought this screening test was impacted by the drop-off in GP visits.

For the National Bowel Cancer Screening Program, there was no clear effect of COVID-19 restrictions on screening activity as it is a home test, though samples did need to be posted.

Albany long haul Still on screening, the Health Minister Roger Cook flagged a new permanent BreastScreen WA Clinic in Albany as well as a new Breast Screening and Assessment Centre in the northern suburbs of Perth. The Albany clinic is expected to screen 3,000 women annually. The permanent clinic will replace the mobile facility that has been operating in Albany for more than 25 years. The new northern suburbs clinic will combine both screening and follow-up assessment and is likely to be located in the Joondalup area with a targeted opening date in the second quarter of next year. continued on Page 12

Race is on We reported earlier in the year that Bethesda Hospital had begun planning a mental health facility in Cockburn to meet some of the unmet mental health needs in the rapidly expanding southern suburbs. SJG Murdoch last month announced that it was also planning a 48-bed private, stand-alone mental health facility on its campus, which would include a specialist youth and adolescent service. Dr Chinar Goel (right) has been appointed the Mental Health Lead. She said there were no private specialist inpatient services specifically for young people anywhere in the State and there was “a clear unmet need in our community”. Architect image of the mental health facility at St John of God Murdoch Hospital

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Consultant geriatrician at SCGH Dr Elissa Campbell is the inaugural recipient of the WA Department of Health Churchill Fellowship. Elissa will work with clinicians in New Zealand, US, UK, Netherlands and Singapore to explore models of palliative care for people living with, and dying from, dementia. Sarah Joyce, Project Director at the department, and Carol Kaplanian, Women’s Health Coordinator from the Women and Newborn Health also were awarded a Churchill fellowship. Armadale GP Dr Ramya Raman is the RACGP’s WA GP of the Year. The award for GP in Training went to Ferndale GP Dr Anastasia Isakova. The General Practice of the Year is Fulham GP in Cloverdale and the GP Supervisor of the Year is Dr Andrew P’Ng, of South Perth. Three WA medical and health researchers are among the 28 who have been elected as fellows of the Australian Academy of Health and Medical Sciences. They are Professor Ian Constable, Lions Eye Institute, Professor Alistair Forrest, head of Systems Biology and Genomics, University of WA, and Professor Lin Fritschi, Professor of Epidemiology, Curtin University. Professor Helen Milroy is among the seven finalists of the 2020 Australian Mental Health Prize, which is decided by the Australian Mental Health Prize Advisory Group. She is the Stan Perron Chair of Child and Adolescent Psychiatry at the Perth Children’s Hospital and UWA. She is also a Commissioner with the National Mental Health Commission, Chair of Gayaa Dhuwi Proud Spirit Australia, Co-Chair of the Million Minds Medical Research Advisory Group, and the AFL’s first Indigenous Commissioner.

NOVEMBER 2020 | 11

IN THE NEWS

The oldest hospital in the St John of God Health Care group, Subiaco, is planning a major building and redevelopment program. The hospital, which opened in 1898, has put plans into the Cambridge Town Council that would add an Emergency Department, a sevenfloor Mother and Baby centre and new medical specialist suites. The plans are open for community comment. Speaking to Medical Forum, the hospital’s chief executive Professor Shirley Bowen said the design had anticipated potential concerns about height and setbacks with extra setbacks from the street and the inclusions of open green space. If approved, the project will be done in stages. The first will be a complete revamp of the always critical engineering plant, followed by the mother and baby centre which will include 66 large bedroom suites, an obstetric theatre, a 26-bed Neonatal Intensive Care Unit, and a Maternal Fetal Assessment Unit. Theatres will increase from 23 to 26 plus a hybrid vascular unit with a new coronary care unit and cardiology ward. The ED would be several years after this. The planned redevelopment will also add 30 new overnight and 20 day beds, plus specialist medical suites a research and education centre plus 222 additional car bays. It is hoped the tender will be awarded by the end of the year and construction started in 2021.

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Mental health boost Neami National has been awarded the tender to operate the 10-bed community mental health Step Up/Step Down service that will be located in Geraldton and the 10bed service that will be located in Kalgoorlie. The state government gave the Mid-West service a push along with an extra $2.4 million so it could open 12 months earlier than expected. Both the Mid-West and Goldfields services will open early next year. Richmond Wellbeing will operate the six-bed Pilbara service which is expected to open later in 2021. The WA Country Health Service will provide clinical supports as part of each of the services.

Radiotherapy report The AIHW reports that the number of radiotherapy courses grew from 61,000 in 2015-16, to 74,000 in 201819 with six in 10 of these courses in the latest period being delivered by public providers. In 2018-19, half of all radiotherapy patients started treatment within 10 days of being assessed as ready for care, and 90% within 27 days. For those who needed emergency treatment (1.5% of courses), 96% began treatment on the same or the next day. The proportion of public patients who 12 | NOVEMBER 2020

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Subiaco thinks big

An artist’s impression of the upgraded entry, the new Emergency Department entrance off Salvado Rd and expanded carpark Source: Silver Thomas Hanley

needed emergency radiotherapy and received it within 24 hours ranged from 92% in Western Australia to 98% in the ACT. The median waiting time in the public system ranged from seven days in SA and NT to 22 days in the ACT. In the private system, the median wait time was eight days. Almost nine in 10 (89%) of the courses were delivered to people aged 50 and over and 1.4% were delivered to patients aged 30 or under. About six in 10 (59%) were intended to cure disease, 49% were palliative and 0.3% were prophylactic.

No CDC on the cards Despite some calls in the sector and a Labor commitment, the federal government did not allocate funds in the budget for the creations of a centre for disease control – which some said was a wasted opportunity during a pandemic. The Australian Healthcare and Hospitals Association (AHHA) Chief Executive Alison Verhoeven said it had been a recommendation to government by the Standing Committee on Health and Ageing since 2013 and overlooked in favour of the development of a National Communicable Disease Framework. “The COVID-19 pandemic has revealed weaknesses in Australia’s planning and response processes. Inconsistent messaging and

conflicting expert advice across jurisdictions were partly addressed ‘on the run’ by the establishment of the National Cabinet, with the Australian Health Protection Principal Committee reporting directly to it. However, this has resulted in a reduction in public transparency about disease control decision-making processes,” she said.

Occupational asthma The National Asthma Council last month released a paper on workrelated asthma to help GPs to manage what it described as underrecognised and under-reported condition. The paper suggests if patients are presenting with newonset asthma or a recurrence of previous asthma, GPs are advised to consider the possibility of “occupational asthma” that is caused by airborne substances (sensitisers or irritants) in the workplace. “More than 300 workplace agents have been reported to cause sensitiserinduced occupational asthma, which accounts for about 90 per cent of occupational asthma,” said GP Dr Ian Almond, who was on the guidelines committee. https://www.nationalasthma.org.au/ living-with-asthma/resources/healthprofessionals/information-paper/hpwork-related-asthma

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NOVEMBER 2020 | 13

Compassion in turbulent times Clinical A/Prof Sarah Cherian heads up a service which helps refugees and migrants find their feet and make their home in a new country.

By Ara Jansen

Somewhere in a probably dusty and long-lost Year 2 scrapbook, Sarah Cherian declared to the world she wanted to be a paediatrician. Who knows if she even spelt it correctly? The point was, she knew. Decades later Sarah – now Dr Sarah Cherian – never deviated from her seven-year-old self and has no doubt gone on to do things that she never would have imagined. Sarah, 45, heads up the Refugee Health Service (RHS) at Perth Children’s Hospital. The RHS coordinates and manages the complex care needs of recently resettled refugee and asylum seeker children up to 16 years old. It comprises a team of specialist medical, nursing, social work, dietetic, dental, mental health, school liaison staff and volunteers offering a holistic service to meet the needs of refugee children, adolescents and their families. The PCH RHS and Community Refugee Health Team work together as the Child and Adolescent Service Refugee Health Service, providing statewide paediatric refugee health expertise. A UWA graduate who did her internship at Sir Charles Gairdner Hospital, Sarah was the first Refugee Health and Infectious Diseases fellow at Princess Margaret Hospital. From there she was one of the doctors who helped build the RHS from the ground up.

Ground up approach “We had to create everything from scratch and had to figure out what we didn’t know,” Sarah said. “There were no national guidelines at the time and most of the paediatric knowledge was extrapolated from adult medicine. Over the past 15 years, our RHS has contributed significantly to the national knowledge and research base. “Before 2006, most of our clinical care was undertaken ad hoc. Our RHS started small. We received Gaps in Care funding in 2006 and started standardising multidisciplinary assessments. By auditing the common presentations in children, we were able to identify further gaps in care, such as pre-school dental health. “Fifty to sixty per cent of newly arrived pre-school children had terrible dental caries which was impacting on growth, nutrition and sleep. Plus, there was nowhere for them to go as public dental programs didn’t

14 | NOVEMBER 2020

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CLOSE-UP

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CLOSE-UP encompass preschool children and parents couldn’t afford private services.” Attending local public clinics is not always easy for this population. Language and logistics provide one barrier, as do potential cultural and familial attitudes towards healthcare. Clinical research into WA community preschool dental pathways and refugee families’ perceptions of facilitators and the barriers of paediatric dental care was undertaken. They identified the clear need for a ‘one stop shop’ for paediatric refugee health where all aspects of care could be addressed and interpreters provided. This led to embedding paediatric dentists into the RHS team, allowing them to facilitate preventative health care as well as offering cutting-edge treatment as part of the interdisciplinary care. “Our RHS model has given families access to the timely care and therapy they need, in a culturally appropriate manner, which is one of the beauties of our team. By incorporating research into our care model, we also continue to build the local evidence base and continue to improve our health care delivery,” Sarah said.

Holistic care The CAHS RHS works with the whole family during the first couple of years of resettlement. The team works together to identify health access barriers including language and literacy difficulties, trauma and broader practicalities related to moving to a new country or being forced to flee one’s homeland. “Over time we help families transition to mainstream health and wider community services. Concepts such as disability and early intervention therapy may be totally foreign to some families. Forty to fifty per cent of the mothers have not had higher than a primary school education, which influences health literacy. “Our multidisciplinary team assists in health navigation and advocacy, especially with processes such as the NDIS, which can be very challenging. This is just one space which shows how important it is to work as a team and collaborate with our patients. We work with many organisations such as the Red Cross and the Ethnic Disability

Advocacy Centre, as well as wider government organisations to help ensure families have a healthy start in WA.” With time, dedication and innovation, the RHS has become the benchmark service nationally, alongside the Royal Children’s Hospital Immigrant Health Service (Melbourne). Both are renowned for their clinical work and research. Future goals include increased multidisciplinary RHS outreach as well as broadening adolescent refugee health care. Approximately 97% of the families who come to the centre don’t speak English when they arrive. Over time, almost 50 different languages and dialects have been encountered. Currently, the most common languages include Arabic as well as dialects from Afghanistan and Burma. “Currently about one third of our families are from the Middle East, a third from South East Asia and the remainder are from Africa. In 2005/6, almost 50% were from Africa and small numbers from the Middle East. As global politics change, the backgrounds of

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refugee families change, meaning our service has to frequently adapt and be flexible. Our RHS population is similar to that of the national intake,” Sarah said.

Growing confidence “Our team see families through a time of considerable resettlement stress and cultural change. It’s really encouraging to see parents starting to answer more questions in English. The positive growth and resilience is just extraordinary. Our families are amazing as they find so many ways to thrive and be successful in a foreign place, yet remain grateful and humble for any assistance received.” These stories of success, no matter how small, are heartwarming and uplifting for the team. Sarah recalls one story related to moving into the new hospital building. One of their parents resettled from a remote Afghani town, brought his family through the hospital to proudly show them the tiling work he had done as part of the PCH building team.

continued on Page 17

NOVEMBER 2020 | 15

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CLOSE-UP

Compassion in turbulent times continued from Page 15 Another story Sarah shares is about two women accidentally meeting during a consultation. They had not seen each other in 20 years when one had taught the other in Burma, who was now resettled in Perth with her own family. “There are so many beautiful stories and some of them quite surreal. There’s a lot of joy in what we do and that’s one of the great things about the service, there’s a lot of happiness. The ability to help create and foster new beginnings for families is incredibly special.” This contrasts with the fact that all the families seen through the RHS have faced immense adversity and trauma before arriving in Australia. Sarah says that’s why holistic intervention early in resettlement is so important and why the team works closely with adult and child health services, education and other specialist refugee network providers. “The factors that influence physical, developmental, socioeconomic and emotional health of a patient are considered for every family seen through our service. By addressing all aspects of health, we also help empower families and help them in making community connections and addressing practical concerns, such as catching public transport to appointments.

Do for others… “A key question to reflect upon, would be ‘If this were your family, how would you want them to be treated by health staff?’ All clinicians in medicine manage families from diverse backgrounds, but how do we as health staff deliver the best care that is culturally appropriate and trauma informed?” Sarah is mother to three children and her husband also works in the field. Choosing to work as a consultant part-time is an important part of her life balance. She has worked hard not to let that decision compromise her career by continuing to contribute to research and teaching while raising her family.

Sarah as seen by one of young patients.

When she was training, Sarah decided working part-time would allow space for the other things she wanted in her life. She says most of her paediatric peers have also chosen sessional consultant careers around family commitments. It has definitely made her healthier and happier. And it seems to have encouraged some male colleagues to follow suit. Earlier this year Sarah won the 2020 RACP Mentor of the Year award, a testament to her leadership, advocacy and support of junior doctors as well as her contributions to paediatric refugee health. She is especially keen for doctors to figure out how to make their lives work for them – to be able to do satisfying work, have a life away from work and find and energy to have families. “There’s a lot of pressure to achieve and have it all as a woman,” says Sarah. “I’ve gathered so much from my role models, decided who and what I wanted to be and used what they taught me to get there, but in the way which worked for our family. “Now to be recognised as a role model has affirmed my decisions. I had to carve my own path and I did feel like I had to work harder

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as a woman. It has been a juggle between work and being at the athletics carnival and making sure there’s food in the correct lunch boxes! “The days I don’t work are my mummy days. I’m still contactable by my team if they need me and I’m always there for my junior staff, so it’s nice to have that balance.”

Role models Sarah attributes some of knowing she wanted to be a pediatrician early on to having strong female role models in her family. “My mother was a significant influence and role model – and still is, due to her work ethic, kindness and ability to support both myself and my brother in our respective endeavours! Mum’s siblings have all been good role models too and have all supported me over the years. “I have a very strong family and I am very close to my mum and brother.” says Sarah. “They both taught me you need to be wellrounded, contribute and give back. Maybe that’s why I went into medicine, because it’s a great career from that point of view.”

NOVEMBER 2020 | 17

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Q&A

Q&A with... Dr Gemma Hounslow, Retired Busselton GP

MF: When and why did you decide to do medicine? GH: It was at the end of high school in 1974! My exam results were better than expected so I changed my option from Physical Education to Medicine (at a cost of $20). Also a few of my friends from school were also doing medicine. There was no ‘gap year’ so we all went straight in. I was 17. Seems crazy now. MF: When you graduated, what were your aspirations for your medical career? GH: To do the best I could and have fun along the way in the hospital setting…and we did! MF: What was the moment you decided to do general practice? GH: I was married and having babies and it just seemed the best fit. I had worked in UK for the NHS in the 1980s and I really didn’t want to do any more exams! MF: Where has that decision taken you? GH: Well, city general practice was quite frankly boring me so we decided to move to Busselton with two small children. The initial plan was a trial for two years, now it’s 28 years later. Time just flew. It was a very busy time. MF: What were the motivations to go rural? GH: Well my husband had been retrenched, I was looking for a more ‘exciting’ practice and a friend also wrote to me to join him in Busselton. The town was growing so it was perfect timing to give it a go in 1992. 18 | NOVEMBER 2020

My husband was also happy to be the primary care giver. This was not so common back in 1992 and absolutely essential if our trial was to work as the on-call commitments were huge. I was doing a 1:3 on-call for all patients and we all shared the on-call for the Emergency Department as well as doing obstetrics. This type of work was unheard of in the city for GPs. MF: What has rural practice given you that you may not have experienced in the metropolitan area? GH: The kids had a wonderful small town/community childhood and made lifelong friends at school. Life was just easier. No commuting hassles. We really didn’t lock the house. I had a much closer relationship with patients and friends. In a small town you are living, working and socialising with patients. Patients become friends and friends become patients! MF: What have been the highs and lows of being a doctor in a small(er) community? GH: The pleasure of looking after several generations of the one family. In one instance I was looking after four generations of one family. It was cradle-to-grave medicine. But that can also give you the lows. One has to live with your mistakes and even see them while you are shopping. It can be a double-edged sword. MF: When did you know it was time to retire? GH: About 12 months before I officially retired. I had been sick and

taking a lot of time off. The increase in paperwork and IT were also getting to me, if I’m honest. Also, medicine is changing. Now everything has a guideline to follow for medico-legal purposes. My husband had also retired early in 2017 and I had been slowing down for several years. It was an easy decision for me. MF: How hard was it to tell your patients? GH: It wasn’t too bad but I had planned it all. I gave myself plenty of time to tell them personally as they came in. This was four to six months before I retired. The staff was also given permission to inform patients as we went along so we were able to give people a final date, which was all planned. There were many gifts and appointments just to say goodbye… and some tears, too. MF: How does life in retirement look to you? GH: Good, even though 2020 has been a strange, weird year for us all. I’ve slipped into it pretty easily and also several friends have also retired so we can go through Irrelevance syndrome together!

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Q&A

Dr Gemma Hounslow with husband Robin Belford in their hometown of Busselton.

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NOVEMBER 2020 | 19

FEATURE

Aged Care in the COVID era Standing at the ready The residential aged care sector in WA has had the grace of time to prepare for an outbreak of COVID-19. Brightwater’s Jennifer Lawrence details some of the plans.

Responsible for 11 residential aged care homes looking after WA’s frail and elderly most vulnerable to COVID-19, Brightwater Care Group has learnt that it can never afford to feel fully prepared and ready to deal with an outbreak of the coronavirus.

Lawrence, highlighting the critical need for WA aged care staff to undergo sufficient training in application of infection control practices and correct Personal Protective Equipment (PPE) donning and doffing to prevent the spread of the virus.

During extensive first-hand briefings and consultations with crisis management experts and Joondalup hospital COVID ward frontline physicians, Brightwater was warned of the need to work constantly at and fine-tune its rapid response. “It is not a set-and-forget situation, you really just can’t do that,” said Brightwater chief executive officer Jennifer Lawrence. “You can never prepare too much and nothing is better than practical preparation and regular scenario sessions. “You can have all the pandemic planning and training, all the documents and policies but when you actually go, ‘Right, let’s say in room number one with Mrs Brown we had a positive COVID. What do we do?’, that focuses staff and helps you understand exactly how prepared you really are. “We are discovering that we need that practical element in order for our people to apply their thinking fully on what is their responsibility during an outbreak. 20 | NOVEMBER 2020

“COVID-19 is by far the biggest challenge the aged care industry has ever faced. We are learning a lot, but it is still something that is an unknown situation. If you look at what has happened across Europe, across America and now in Melbourne, they too probably thought they were prepared. “You can’t understand in advance how difficult dealing with an outbreak will be. And I think one of the biggest challenges will be with staff, because during an outbreak they will be scared for themselves and their families and I understand that.” Victoria’s recent outbreaks resulted in approximately 70-80% of healthcare workers with COVID-19 being infected at work, said Ms

“Brightwater has introduced mandatory hands-on PPE competency checks,” she said. “We learnt how important this was from Joondalup Health Campus, which did not have a single healthcare worker infection when dealing with passengers from the Artania cruise ship. Joondalup had someone observing their staff putting on and taking off PPE, so we are doing that too at all our aged care homes. “Our staff undergo the Commonwealth-mandated training, the additional training we developed ourselves and this nurse-led observational auditing. “Now the WA Department of Health has issued PPE for training purposes to all WA aged care sites so staff can practise, which is vital because smaller providers just can’t afford to use PPE for this.” A novel virus with a worldwide death rate now surpassing one million, COVID-19 has hit Australia’s shores at a time senior citizendemanded Government reforms

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Marnie McKimmie reports

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FEATURE

have transformed the aged care industry from a “medical and nurse-led model” into a “social and home-like carer-driven model”, with onsite nursing and allied health professionals and hospitals providing acute medical care when needed.

combined forces to share information, ideas and support each other to prepare for an outbreak by working collaboratively with the WA Department of Health and providing input into the WA COVID-19 Residential Aged Care Facility Outbreak Plan.

“But with the pandemic, it is very different in that the Government approach has been to keep elderly people in aged care homes and most homes have not had the clinical expertise in the numbers they need,” said Ms Lawrence.

“This is a live plan and we are meeting fortnightly as a group to review, revise and apply any learnings from overseas and interstate,” Ms Lawrence said.

As had been seen in Victoria, aged care systems and infrastructure that had dealt well with flu or gastro outbreaks had not coped with COVID-19 because of the “extraordinary circumstances” – the virulence, the numbers and the infinite time frame. More than 200 Victorian nursing homes have had coronavirus outbreaks, claiming the lives of more than 600 people, reports ABC News. Continuing to watch and learn from outbreaks elsewhere gives WA the best chance of protecting its older citizens, said Ms Lawrence. Since March, CEOs from six of WA’s larger aged care providers, including Brightwater, have

“The industry and WA Department of Health together have now estimated that during an outbreak one WA aged care worker will need to change their PPE 30 times a day and we have been reassured that there is enough PPE available from Government warehouses to cover the state. “Brightwater has some PPE onsite and has worked hard to build up our own stockpile, ready to be deployed.” Concerned by reported huge staff losses during outbreaks in Victoria, Brightwater has been busy establishing a pool of skilled aged care staff on standby ready to step in at a phone call to assist and replace those forced into quarantine – including nurses, carers and hotel service staff.

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“The industry and WA Department of Health together have now estimated that during an outbreak one WA aged care worker will need to change their PPE 30 times a day”

“We have in place a casual pool of trained staff who could be a replacement workforce if required and we are also currently recruiting a specifically trained surge workforce incorporating people from across our business who could be put straight into an infected site if the existing staff have to selfisolate.” Paid special sick leave is now provided by Brightwater so staff who are unwell are confident they can stay at home without any financial implications. Brightwater has also increased

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NOVEMBER 2020 | 21

FEATURE

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Aged Care in the COVID era continued from Page 21 efforts to understand where else its employees work and may potentially be exposed to the virus – whether it be part-time work at another aged care provider or in a supermarket. Ms Lawrence said that previously, not all carers had wanted to share details of other jobs, preferring to keep this information confidential. A large proportion were born overseas and often may not have the same level of trust in governments and information sharing. “While the South Australian Government has restricted some aged care workers from working across multiple sites, in WA, aged care providers are currently not able to force workers to only work on one site,” said Ms Lawrence. “In South Australia this has been enforced with no additional

22 | NOVEMBER 2020

funding to assist providers and employees with implementing this arrangement. In the event that the WA Government makes similar directions restricting workforce

movements between WA aged care facilities, measures would need to be put in place to ensure that adequate support is provided to staff and that the employment

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FEATURE

conditions they are entitled to – including work hours – can be met.” She added that the extra government funding to aged care during the pandemic had only met a “small proportion” of the additional costs incurred by providers preparing for an outbreak. “The Government initiatives were very welcome, including additional payments for each residential aged care and home care client plus the Aged Care Workforce Retention Bonus,” she said. “It is disappointing that some employees were excluded from the bonus scheme, including Hotel Services Employees and those working in transitional care and with Commonwealth Home Support Package clients. “To ensure all our staff felt valued during what have been very challenging times, Brightwater made the decision to ensure that

every employee with direct client contact got the retention bonus by funding the payment for those staff not covered.”

either by telephone or by video calls, and this is something we have encouraged in the case of an outbreak at a residential site.

A key component of Brightwater’s rapid response preparations for the challenges to come has been improving communication with GPs to clarify their role in the event of a residential home outbreak.

“On-site nurse practitioners, authorised to provide advanced clinical care without GP supervision, have a role to play during this pandemic, but it is hard as there are not a lot in WA with this qualification.

“If a client were to test positive, all GPs providing services at the affected site will be alerted immediately – this is critical. The GP will then work with the WA Department of Health and the provider to ensure appropriate and continuing care. “GPs can provide timely information to relatives about residents as well as provide on-site support in monitoring the condition of residents, prescribing medications and renewing prescriptions.

“It is really important that everyone knows the process and where they need to provide input so we make the right decisions during an outbreak. We have to avoid what has happened in others parts of Australia where there have, at times, been too many people involved.”

Read this story on mforum.com.au

“Many GPs now use telehealth (where clinically appropriate),

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NOVEMBER 2020 | 23

FEATURE

Aged Care in the COVID era Are we ready? A GP perspective

We are very lucky here in WA. If we had had to deal with community spread of coronavirus in aged care earlier this year, we might have been in just as much trouble as the eastern states. We have had the luxury of watching and learning from their experience. Let’s hope we have learned wisely. Every Residential Aged Care Facility (RACF) in WA has drawn up a plan for management of the pandemic. There has been extensive consultation with the Health Department. However, it would seem that general practice has been mostly left out of the discussions and planning. It is assumed that GPs will take their part in the overall management of any outbreak, but what would that entail? Contingency planning for coronavirus in RACFs has shown up some of the cracks in the system. Many staff have traditionally worked in casual positions across numerous facilities, with inadequate financial support to take time off when sick. RACFs must address these problems with the system, to ensure that staff are able to make a living wage without having to compromise their own health and that of the aged residents. But what of GPs attending RACFs? Are we expected to also restrict ourselves to only attending one RACF? Should we attend a RACF

24 | NOVEMBER 2020

straight from our surgery, possibly carrying infection with us? Who will provide our PPE?

Navigating the system In our traditional small business model, it would seem that each of us is on our own and must develop our own plans. The RACGP has published and updated guidelines, but coronavirus infection is so new to us all that we must constantly upgrade our knowledge and policies.

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I think every GP working in aged care should have a frank discussion with each RACF they visit, and with their colleagues, and decide exactly what they will and will not do once we have community spread. Some of the issues to consider include: • Will you attend the RACFs? Will they actually let you in? What will you wear, so that you do not carry infection in? What about fomites on your trusty stethoscope and doctor’s bag? • Are you in a high-risk group yourself, and if so, who will take on your RACF workload? • How will you prevent taking COVID home to your family? • Think about what you can and cannot do via telehealth as a GP. Make sure your technology is up to the task. Can you easily contact the Registered Nurse? Can you

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access the RACF’s IT system and medication charts? Are your notes adequate if an unfamiliar doctor has to take over from you? Do you have contact details for all your residents’ next of kin? Do you have a good working relationship with the pharmacy that supplies the RACF? Is there an imprest system, particularly if antibiotics or opiates are needed at short notice? Are you able to socially distance in the workplace? (LOL) Mask wearing is recommended in circumstances where social distancing is impossible. That means when examining patients, and when in the cramped nurses’ office. Consider wearing gloves when using shared equipment such as desktop computers and telephones. Remember that the tea room is the most dangerous place for transmission. Think about the practicalities of segregating COVID-positive patients in each RACF. Some facilities are built in such a way as to allow easy separation; many are not. Facilities need to plan for having separate groups of staff caring for positive and negative residents. The latent period between infection and symptoms means that separating positive and negative residents will never be an exact science. There needs to be surge planning for staff who have to isolate. And not just the nurses and carers!

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Dr Cathy Parsons has been working in aged care for the past decade and offers these perspectives on the sector and its readiness for a COVID outbreak.

FEATURE

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eastern states there have been instances of people with agitated dementia and COVID having to be admitted to tertiary hospitals and heavily sedated in order to protect other residents at their RACF. • Supplies of PPE are in a better state now than they were at the outbreak of the pandemic. But in the world of General Practice, it seems to be everyone for themselves. If you don’t have a personal supply of PPE, now is the time to get online and order some. Think about what you will wear for different situations. Think about protecting yourself, and also about preventing spread of the virus to others.

What about when the chef, cleaner and handyman are sick? • Managing COVID in the context of dementia and cognitive impairment is extremely challenging. The lack of family contact has a terrible effect on those with dementia, as we have already seen here in WA. In the

There has been much discussion about where to care for RACF residents with COVID. Moving everyone into a tertiary hospital is simply impractical, not to mention desperately unpleasant for many elderly people who would rather not die in a strange place, surrounded by strange people who cannot touch them.

Stay or leave? Likewise, keeping everyone in their RACF is also not a viable option. It is unfair to the other residents to expose them to infectious patients,

and RACFs do not have the capacity to care for a large cohort of desperately ill patients. RACFs were never designed to be acute hospitals. An option which has not been fully explored may be to provide facilities which are specifically fitted out to be infectious disease wards to nurse people who have high care needs but who are not in the groups who would benefit from being in an acute tertiary hospital. Decommissioned hospitals or other large community facilities such as sports halls might lend themselves to this purpose. And a final note: never mind the RACFs, are our General Practices COVID ready? Are practice owners providing a safe work environment as required by law? Will we have workers’ compensation claims when staff contract COVID-19 in the general practice workplace? What a brave new world! Are we ready to take it on? ED: the author wrote this piece when WA had no community spread of COVID-19.

Specific Advance Care Planning for RACF residents Advance Health Directives are hard gigs at the best of time. COVID is making them essential, says GP Dr Cathy Parsons. The subject of Advance Health Directives (Advance Care Plans) is an area of mixed opinions among practising doctors. Many believe they are extremely valuable, whilst others see the limitations and even dangers when people confuse ‘not for resuscitation’ with ‘no active treatment’. Regardless of each doctor’s personal bias, in the time of the Coronavirus pandemic an Advance Care Plan is something that will be expected for every COVID-19 patient, whether or not they are hospitalised. There are lessons we can learn from what has been happening elsewhere in the world and in Australia. As

GPs we can help develop a written plan before the situation becomes urgent. We can raise the topic of death in a sensitive way, that acknowledges its inevitability for ALL of us despite the best efforts of modern medicine. The management team for COVID patients in (or from) Residential Aged Care Facilities (RACF) is likely to be made up of clinicians who do not know the patient or family, and who will be under pressure to make decisions quickly. The management team may not include the GP. The family will be expected to give clear directions on escalation of care.

Mixed quality Most RACF residents these days

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have an Advance Care Plan on file. In my experience, the quality and legality of these documents is variable, and they were mostly compiled before the emergence of the pandemic. We can be proactive in updating such documents and educating patients and their families. I find that meeting with the family at a case conference is an effective way of helping people understand the issues and practicalities, as well as allowing an opportunity for questions. Before asking people to make decisions about treatment, it is continued on Page 27

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Aged Care in the COVID era continued from Page 25 important to explain what we know about treatment of COVID-19 in the aged population, such as the following: • We do not have a cure. • Despite treatment, a significant percentage of frail aged patients who get COVID-19 may die of it. Intensive treatment including artificial ventilation has so far not been very successful in treating the elderly. Most people over 80 years can expect NOT to be considered for mechanical ventilation because of its low success rate in this group. • All patients with COVID-19 would be offered nursing care to improve their chance of recovery. • Medical and nursing interventions can be offered to treat potentially curable complications, if recovery seems a possibility in that particular case: For example, intravenous fluids for dehydration or antibiotics for potentially curable secondary bacterial infection. • There are some complications that we cannot cure, particularly in people whose condition was frail to begin with. • If death appears inevitable or likely, there is a lot we can do to

aim for a dignified and peaceful death, whether that is in hospital or in an aged care facility. However, it may be impossible for next of kin to be present. • Not every COVID patient will be considered appropriate for hospital treatment either because they are not sick enough or because they are too ill to be expected to have a chance of recovery. The Health Department or the hospital admitting officer will decide the ceiling of care; families should not expect to be able to override that. For example, intensive treatment would be unlikely to be offered to people whose pre-existing health problems mean they are unlikely to recover. • An important part of Health Department decision-making relates to prevention of spread to staff and to other residents. This may influence where a COVID patient can be accommodated, and the family may not be given a choice. Family visits would generally be forbidden. • The patient’s own GP may not be able to be involved in COVID care. We should, however, reassure patients and families that endof-life care is something we understand and frequently practise

in aged care, and that we will always aim for dignity and comfort when we cannot provide cure. It is also helpful to explain to families what measures the RACF and the GP are taking to prepare for a COVID outbreak. In other states we saw major issues with communication between RACFs and families. It is vital for both the doctor and the RACF to maintain an accurate database of contact information for each resident’s decision-making next of kin. The time for upskilling in the use of technology for telehealth consultations is now: before the next wave. Residents can often be assisted in how to use technology, and GPs can make sure we have remote access to IT systems including medication management. PPE training and stockpiling should be well under way. Here in WA we have found ourselves in one of the luckiest places in the world with respect to the pandemic. It is tempting to let our guard down, but I think we would be better off ensuring we are well prepared. Helping patients and families develop their own COVID plans is a useful thing we GPs can do.

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FEATURE

Aged Care in the COVID era Inquiries fall on deaf ears

The outbreaks of COVID-19 in Australian aged care facilities have exposed a system that was broken long before the pandemic arrived as evidenced by the ongoing Royal Commission. Despite clear warnings from overseas and the terrible outbreaks in Victoria, we still have no overall strategy to prevent COVID-19 in aged care facilities. The Government’s approach has been, at best, a series of ad-hoc funding announcements thrown at the crisis with little, if any, transparency or accountability.

for-profit providers, only makes this situation worse. It’s clear that the infection control procedures put in place in residential aged care haven’t been up to scratch for a long time.

Success story In 2019, 837 older Australians died from influenza in residential aged care facilities. This year only 28 older Australians have died from influenza to date. The improved infection control procedures put in place to fight COVID-19, have

highlighted what can be done to prevent deadly outbreaks of other diseases in aged care. The government has known about problems with the aged care workforce and inadequacy of care provided for years. Facilities still do not have the right staff mix to look after older Australians and prevent future outbreaks. There are not enough staff with appropriate qualifications to provide clinical care, infectious disease control and this is compounded by a lack of training.

One of the issues that this pandemic has clearly reinforced is the failure over years to address workforce issues. There have been countless reports. I chaired an inquiry responsible for one of those reports but recommendation after recommendation has been ignored and remain unimplemented. Across the country and particularly in Victoria, the casualised, underpaid and under-trained aged care workforce played a role in spreading COVID-19 across facilities. This was because aged care workers had to work across multiple facilities to earn a living, didn’t have enough Personal Protective Equipment, were not adequately trained in infectious disease control, didn’t have the clinical leadership and didn’t have the workforce numbers to meet demand. Years of under-investment in aged care, on top of a drive for profits by

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Senator Rachel Siewert

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WA Senator Rachel Siewert chaired a Senate inquiry into aged care five years ago. Nothing has changed and it has costs lives. She shares her views here.

FEATURE The truth is that most residential aged care facilities don’t provide enough hours of care to residents. We need massive investment in the workforce to increase the hours of care provided to residents (which means more staff), increase pay for aged care workers by 15% and an adequate mix of staff skills to provide the level of care needed, including having at the very least one registered nurse working 24 hours a day, seven days a week in all aged care facilities.

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If we are going to protect older Australians from the spread of COVID-19, we must invest in our workforce. Not only are we failing older Australians but we are ignoring an entire area for economic growth – our caring economy.

and again and that we have ended up in such a desperate situation. Australians are horrified by how rapidly COVID-19 spread through aged care facilities.

WA to check their infection control procedures. Without more checks and audits, how can we know if we are prepared for COVID-19 outbreaks in WA?

In my opinion the Aged Care Quality and Safety Commission has not taken a strong enough approach in assessing and monitoring facilities during the pandemic.

Bureaucracy fail

The commission has focused on assessing a providers’ readiness through self-assessment via online assessment tools and telephone calls. Guess what – most in Victoria thought they were ready! How is self-assessment appropriate in the middle of a pandemic?

Lesson not learnt

I am certain the commission does not have the resources nor the staff to conduct face-to-face riskassessment and infection control audits of every facility in Australia. In fact, the Australian Defence Force have conducted more checks on aged care facilities than the commission.

The things I am saying are not new and it's incredibly frustrating that they have to be said again

As at September 11, 2020, the commission had only visited 11 residential aged care facilities in

Here in WA we have been fortunate so far but we cannot be complacent and it doesn't mean that we can’t learn lessons from the outbreaks in other states.

We have known about the tick-box approach to assessing aged care providers against the standards for years now. People who has worked at a residential aged care facility will tell you that quality assessors are not adequately equipped to do their jobs. This government has again failed older Australians and their families by failing to bolster staffing and resources for the regulator. The Government cannot use the excuse of the Royal Commission not to act and must include significant reform measures. After more than 35 public reviews of the aged care sector in 40 years, we need to reform aged care so that older Australians and their families can age with dignity.

Read this story on mforum.com.au

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NOVEMBER 2020 | 29

FEATURE

Why I love my job in palliative care

I’ve never found a speciality in medicine that engages my passion for helping a wide crosssection of people, my interest in pharmacology and the sense of making a difference when it matters most. But the most common question I encounter when I meet someone for the first time is, “Palliative Care? Doesn’t working around death and dying make you sad or depressed?”. The truth is, it doesn’t. Of course, I empathise and sometimes cry (often, actually, it is my release and it’s human to express emotion). However, for many nurses and doctors working in Palliative Care, it is our calling, our found passion. Our work with the dying is how we find meaning in life. We share this sense of meaning and joy in providing hope and relief for those who are suffering. But not all days are the same. There are dark days in Palliative Care, days you’d rather forget and ones that live in your memory uncomfortably forever. However, those who work in Palliative Care don’t blindly enter the world of the dying with little protection for ourselves. The practice of intentional self-care

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that I’ve seen among the professionals working in palliative care is abundantly clear and built into the fabric of their lives. We understand that we will hear stories of loss, powerful cries of regret, witness suffering and extreme pain and be engaged in conversations that are actively avoided by many.

The dark days We had a dark week here not too long ago. We had two young patients die and we were dealing with several patients with difficult symptom issues, family distress and difficult decisions to make. The atmosphere in our small office was thick with tension. Sometimes there are no words and yet we all know this is a safe place to express emotion, a judgement-free space to express our doubts, fears and complaints. An environment where ethical debate can occur. A culture that expects you to take time out for yourself regularly. The one powerful aspect that I am learning about in the practice of good palliative care is that it takes maturity and wisdom and that only comes from self-reflection and selfcare.

I have learned a great deal about myself in the past seven years in being a country general practitioner – my vulnerabilities, my energy levels and the need for replenishment and self-care, my beliefs and understanding of death and my life philosophy and spirituality. Underlying everything that I do in palliative care is this thought and presupposition about my health and wellbeing: “I can only care for others if I make it my priority to care for myself.” I exercise every day because it creates energy within me. I have every Saturday completely OFF (except when I am on-call) to disconnect and do things that make me feel happy and replenish me because this creates margins in my life and replenishes my energy stores. I ensure that I connect and talk with my wife every day and take a break every year together because it keeps our marriage strong. We go away each year with our sons because this is our time to experience the world together and gives me something to look forward to which anchors my year. I take time out every month to connect with my spiritual mentor because this self-reflection is important to keep me focused on who I am as a man.

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Albany doctor Jonathan Ramachenderan, whose blog, theHealthyGP, is gaining wide readership, writes here about his work and life and how he manages them both.

FEATURE Yes, sadness exists and broken bodies are getting closer to ultimate healing in death, but in this powerful ritual, she is setting the intention that ‘work has finished’ and readying her mind, body and heart to reengage with her family life. This has been a life-saver to me, my family and my wellbeing. Brendan Burchard, in his book, High performance Habits says high performers “set intentions” about what they would like to see and achieve. With this in mind, I started to set the following intention, each time I arrived home after work. “Work is over, I set the intention of presence, peace, fun, laughter and hope.”

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Home zone

Talking and listening I debrief regularly with our nurse manager and my clinical supervisor about the difficult cases we encounter because their perspective on my performance and the larger vision of palliative care is valuable. That still leaves dark days. Before Christmas, I shared with our Palliative Care Coordinator that I wasn’t okay. She’d said something in passing that triggered an unexpected emotional response in me. “This is likely to be their last Christmas”, she said, referring to a group of our patients with children a little older than mine. My chest tightened and stomach churned and tears filled the corners of my eye. I wasn’t okay with that thought and it circled my mind for days, finding no rest and meaning. As we were about to start our clinic, I shared with her how much this thought had affected me. I couldn’t change their prognosis, nor could I make them live longer, but it had stuck close to my heart as I thought of MY young children and the joy of Christmas. Hiding your emotion over time is destructive to your life energy and will eventually lead to you being depleted and broken. I don’t think you can be an effective palliative

care professional if you don’t allow your heart to be softened by the stories of your patients. We had a clinical debrief a few months ago and I learnt something profound from one of our longserving hospice volunteers — a beautiful witty retired Scottish nurse. As she leaves the hospice after each volunteer shift, she physically pretends to take off her ‘hospice jacket’ and brush ‘the worry and sadness away’ and puts on her ‘home and outside coat’. What she is doing is engaging in a ritual that helps to reminds her that ‘work has finished’.

With my eyes closed and a few mindful breaths in my car in the hospital carpark, I set this intention. This reframes my thoughts and sets my mind on what to expect at home – usually mealtime chaos, but also my lovely wife, children and sanctuary of Ramachenderan home life. In the past year, I have begun to share my thoughts to audiences on my blog about ways that healthprofessionals and anyone engaged at the front-line of raw humanity can intentionally build self-care into their lives and thrive in their chosen field. If you would like to know more, please send me a message or leave a comment, I’d love to hear from you and your story, as I have so much more to learn. ED: Jonathan blogs at https://thehealthygp.com/

What I learnt from Doug The surgical ward is no place for a dying man. Doug was 52 years old and had been diagnosed with metastatic non-small cell lung cancer only four weeks earlier. He’d finally dragged himself to see his local doctor for no other reason than to refill his regular pain prescriptions. A simple chest x-ray showed the reason for Doug’s persistent cough and chest wall pain. He had large right-sided lung tumour that was causing

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compression of the major blood vessels reducing his ability to breathe without pain. Doug rolled around on his bed uncomfortably. He couldn’t lift his eyes to make contact with us as we stood in his room trying to assess and deduce the best clinical course of action. He could only respond in monosyllabic tones, “yeah” and “nah”. He was barefoot and tall, dressed in tight fitting black jeans and a blue continued on Page 33

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FEATURE

What I learnt from Doug continued from Page 31 shearer’s singlet which clung to his thin but well-defined chest. His long black hair covered his face and through the strands of his fringe, I finally made a connection with his dark brown eyes. He was scared. He was alone. In stark contrast to the blue skies and radiant autumn sun bursting through the shutters of Doug’s single hospital room, he asked Lesley, the nurse who was with me, “Is it happening now? Am I going to die?” He was the first patient I’d seen in many years, agitated and so obviously in pain. With so many thoughts running through my mind, I struggled to know what to do next which is so often the case when clinical reason is flooded with emotion and psychological distress.

due to tumour progression and we expected his course towards his death to be turbulent. Cancer shows no respect to the people it afflicts. It is both demoralising and destabilising to a person’s resolve. Desperation is often what we see, a loss of choice and sometimes, devastatingly, a loss of hope. This is the space in which Palliative Care works to restore hope in providing quality of life in the relief of symptom burden, supportive care for family and patient and most importantly the prevention of futility in the face of human physiological and psychological frailty. Acute pain is always an emergency, especially in our palliative care population. I’ve learnt that escalating and unremitting pain is almost always associated with the fear of imminent death in our patients. Often this can be the case

but the treatment of pain crises in palliative care is regular occurrence, physiologically due to disease progression. Doug’s story is important. It has taught hundreds of people about benefits of good Palliative Care. The last few months of his life is important to me because unlike any other patient I encountered in my training, the story of his life was intriguing and as we walked through his last days as a patient in our hospice, we learnt about forgiveness and reconciliation, the importance of completing end-oflife business and saying goodbye and how even in the midst of severe suffering, the practice of palliative care can bring hope, relief and ultimately eternal healing. – Dr Jonathan Ramachenderan

Read this story on mforum.com.au

Who is this man? Why is he in so much pain? Why didn’t his doctors call us sooner? Is he going to die in front of me? Who is Doug? We immediately started a subcutaneous infusion of morphine and midazolam to help calm his pain and settle his agitation. The doses that we calculated was astonishingly high due to Doug’s background of chronic pain. I learnt later that he’d been in excruciating pain for at least a week and had recently returned from our tertiary centre on a bus with only a few day’s supply of pain medication. The tension in his body eased into the slow rhythm of his breathing, his eyes were closed in momentary relief, and emotion in the room eased. Thankfulness could be seen in the eyes of the ward nurses who were previously desperate and stunned at the ferocity of Doug’s unrelieved pain. We’d helped to bring Doug relief. It was as if we’d found calm waters in the rough seas of what lay ahead. As we examined his scans, we could see that Doug had a superior vena cava obstruction MEDICAL FORUM | AGED & PALLIATIVE CARE ISSUE

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  34 | NOVEMBER 2020

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FEATURE

Guiding the dying Claire O’Berry meets people at the end of their lives, but she says it can also be a time of joy. She tells Ara Jansen there’s also happiness in a task which might seem impossible to some.

Being thrust into an unexpected situation gave Claire O’Berry the skills to take into her next career. In 2005, both her parents got sick and Claire unexpectedly became their carer for the next six years. With no background in elder care, she had to work through everything from legal paperwork to advocating for her mother to die at home. The skills and the navigation needed to help her mother die her way led to Claire becoming an End of Life Doula. Over the past decade, doulas have become more commonly known for being employed in pregnancy support and birth, but not so well known are doulas helping at the other end of life. Consider them the professionals who guide the dying. An End of Life Doula is a nonmedical role providing support, options and education to assist the dying and those around them to have their end of life unfold in the way they want. They aim to preserve quality of life, wellbeing and self-worth up to and beyond

the end of life as we know it. They help maintain a sense of calm for the dying and open the conversations about taboo subjects around it. “Helping my parents was the hardest and the best time of my life. It’s hard to describe,” says Claire a former actress and notfor-profit manager.

Own terms “I was learning on the fly and hoped I was getting the best advice from people. Both of my parents had one goal – that they would die at home. Even though they were in and out of care I was always the consistent caregiver. And they did. Both of my parents died in their own time at home surrounded by loved ones.” Helping her parents die on their terms and creating an atmosphere of love, calm and understanding inspired Claire to want to create that for others who were dying and for their families. Especially she says when there can be so much fear around dying. Others came to Claire and she started helping people plan and

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be active in their deaths but didn’t realise until later that the work she was doing actually was a profession and had a name, also sometimes called the disliked moniker, death doula. She found a teacher from whom to learn what she didn’t know and start her journey. Claire says she loved every minute of it. “I think the people who do this work do have some kind of calling. It’s something I’m passionate about – working one-on-one with people but also campaigning to help change public policy in end of life care.” Ideally, Claire likes to work with a patient and their family from the time of their diagnosis until after their death with follow-up bereavement care for the family.

Making a plan It starts with getting paperwork in order and making an End of Life Plan, talking about the patient’s wishes about how they want to live their last weeks and their final day. They discuss details about whether continued on Page 37

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FEATURE

Guiding the dying continued from Page 35 people want to die at home, with friends and family around, with music, pets or any rituals or rights they want performed. “Then I try and fill in the gaps of the things which need to be considered. It’s always about supporting what they want. Sometimes that includes facing things with them that they are in denial about or are fearful of. A good doula can anticipate transitions before they happen, knowing what needs to be put in place. “Do they want aggressive treatment until the end or early palliative care? Do they want a burial or cremation? Do they want a green burial, have their ashes spread at sea or a service at a funeral home? When you’re sick, you don’t always have the energy to put these things in place by yourself. “I read a study in the American Journal of Hospice and Palliative Medicine that if someone is even curious about death, 80% will have a more peaceful passing compared to people who are closed off to it. I have my own set of beliefs but I don’t put them on anyone else and try to find out what my clients believe and what’s important to them. Having these conversations really make a difference to the quality of the end of our lives.”

Being there Sitting vigil and being a witness is a big part of Claire’s work. Sometimes she ends up helping families heal long-time emotional rifts and those conversations, she says, can help the dying make peace. She also stresses it’s not her job to be a doctor or an estate lawyer, but to make her client’s interactions with them as smooth as possible, if need be. Currently living in WA, Claire is a Texan and her husband Terry was born in New Zealand. Together they run Dying Your Way and normally split their time between the US and Australia. They are currently working with overseas clients online but are allied to doulas in other cities who can provide in-person support. The pandemic has given the pair the opportunity to create a more comprehensive website and have published a free e-book called Facing Death. Their website provides lots of free resources on topics such as downsizing, book recommendations and links to providers, funeral planning and podcasts with leading voices in the death and dying movement. There’s also a paid portal program to step you through creating an individual End of Life Plan in the privacy of your own home.

“A lot of people just don’t know what to do next, plus everyone’s situation is different. We want to give people access to as much information as possible to give them general support. Then, if they need specific support, we’re also available.”

The positives To some it may seem like a depressing profession, but Claire says it’s hugely satisfying and rewarding. Helping someone leave the world on their own terms can be uplifting and inspiring. “One of the beautiful things about death is when you come up against it, you have to turn around and look back. Then you have a chance to put things in perspective and see that past hurts are not as important as you held them to be. “I have a purposeful joy about supporting people at the end of their lives. While it’s mixed with grief and pain, there’s also love and joy. It’s a sacred moment when someone passes.” ED: Claire was a keynote speaker at the South West Wellness Symposium, organised by GP Dr Sarah Moore and others. A panel discussion with Albany palliative care physician Dr Kirsten Auret, civil celebratant Diane Moore, Catholic vicar Tony Chiera and natural therapist Tricia Lee followed. www.dyingyourway.com

Opening 5th October 2020 Sexual Health North, in Joondalup, is a new specialist clinic for Perth’s Northern suburbs. We offer a wide range of services for our patients from the diagnosis and management of STIs, HIV, PrEP, Hepatitis B & C, trans and gender diverse health care for those over 18 years old, genital skin conditions and vulvovaginal medicine. Our clinic strives to create a friendly and knowledgeable service in an open-minded atmosphere. We aim to work with our colleagues in primary care and specialist settings for the total wellbeing of our mutual patients. In order to help reduce the rates of STIs in our community, we offer our patients the opportunity for on-site consultation, pathology/investigations, and medication dispensing with many acute STI treatments. For acute STIs, we try to keep fees to a minimum. You can contact our friendly team to discuss your patient’s needs.

Dr Christine Dykstra

Dr Michelle Yong

3/5 Regents Park Rd, Joondalup WA 6027 P (08) 6119 9140 | E enquiries@sexualhealthnorth.com.au Healthlink EDI: shealthn | www.sexualhealthnorth.com.au

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NOVEMBER 2020 | 37

Not just PERTH Urology Clinic Albany Geraldton Mandurah

Working together to provide comprehensive urological care Dr. Jeff Thavaseelan Dr. Trenton Barrett

Dr. Shane La Bianca Dr. Andrew Tan Dr. Akhlil Hamid Dr. Matt Brown Dr. Manny Saluja Dr. Anna-Lena Brink

Hollywood Clinic

refer@perthurologyclinic.com.au

Wexford Clinic

Suite 15 / Ground, Hollywood Medical Centre 85 Monash Avenue, Nedlands WA 6009 Fax (08) 9322 5358

1800 4 UROLOGY (1800 487 656)

Suite 23 / Level 1, Wexford Medical Centre 3 Barry Marshall Parade, Murdoch WA 6015 Fax (08) 6225 2105

Healthlink: puclinic

www.perthurologyclinic.com.au 38 | NOVEMBER 2020

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Health and ageing Some lament the fact that they are getting older but as my late mother used to say – what is the alternative.

Australia, like other countries is facing massive debt and there will not be buckets of cash for the health system. In turn we need to respond by thinking laterally and look for innovative solutions.

To say that aged care has been in the spotlight this year both with a Royal Commission and COVID-19 is a massive understatement. Yet despite truckloads of cash and massive regulation at state and federal level, we don’t appear to be getting it right. Or maybe we just don’t hear about the positive side of aged care as it is less newsworthy. Hard to tell. There certainly does not appear to be a rush for the entrance gates. Many years ago, Patch Adams (the famous clown doctor) gave a talk to a group of doctors in Perth. I was honoured to have a photo taken with him. He asked those present to put up their hand if they wanted to end their days in an aged care facility. You can guess how many hands went up. His next question was more pointed – so why do we keep building them? The answer is at once both obvious and also perplexing. Can we do better? Of course, we can. Is the solution to beat up those currently doing their best? No, it’s not. Is more of the same going to suffice? This month we look at aged care in a broad sense. Falls prevention is an area where simple interventions can make a significant difference. Ultimately the end comes for all and decisions on how people want to die is a taboo topic which needs to stop being taboo and actually discussed. This is examined. Staying in better health as we age makes it more likely that we can remain independent. New research in use of colchicine for secondary coronary artery disease protection, testosterone in reducing type two diabetes and neuropeptides in ischaemic stoke are covered together with a Perth first – the use of radiation therapy to treat a cardiac arrythmia. Australia, like other countries is facing massive debt and there will not be buckets of cash for the health system. In turn we need to respond by thinking laterally and look for innovative solutions. A lazy “please sir we want some more (money)” will not be sufficient. Helping people stay healthier as they age can reduce demands on both the health and aged care systems. Genuine prevention of illness and maintenance of health will need to be the focus going forward.

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CLINICAL UPDATE

Testosterone to prevent type 2 diabetes mellitus in at-risk men By Dr Bu B. Yeap, Endocrinologist, UWA and Fiona Stanley Hospital Middle-aged and older men who are overweight, tend to have lower testosterone levels. This is associated with higher incidence of type 2 diabetes and metabolic syndrome. Obesity and medical co-morbidities contribute to the decline in testosterone levels. A review and meta-analysis of observational studies, found that men with testosterone levels ≥15.6 nmol/L had a 42% reduced risk of type 2 diabetes, compared to those with testosterone levels ≤15.5 nmol/L. A non-randomised, observational study of men with pre-diabetes (HbA1c 5.7-6.4%) and testosterone levels ≤12.1 nmol/L receiving testosterone, compared to those who did not, associated testosterone treatment with lower risk of progressing to type 2 diabetes. Randomised trials of testosterone in middle- and older-aged men, report reductions in fat mass, and increases in lean mass, which would be expected to reduce the risk of type 2 diabetes. A large Australian, multicentre, randomised, placebo-controlled trial (RCT) sought to test if testosterone treatment reduces the incidence of type 2 diabetes in at-risk men. Testosterone therapy to prevent type 2 diabetes mellitus in at-risk men (the T4DM) study recruited men aged 50-74 years, waist circumference ≥95 cm, baseline serum testosterone of ≤14 nmol/L, and either impaired glucose tolerance (IGT) or newly diagnosed type 2 diabetes on the basis of screening oral glucose tolerance testing (OGTT, 2-hour glucose ≥7.8 and ≤15 mmol/L). Men were excluded if any of the following were present: hypothalamo-pituitary-gonadal (HPG) axis pathology, testosterone treatment in the past 12 months, any anabolic steroid abuse, medications affecting the HPG axis, previously diagnosed diabetes, 2-hour glucose >15 mmol/L on OGTT, haematocrit >0.50,

(12.4%) in the testosterone arm and 87/413 (21.1%) in placebo arm (relative risk 0.59%, P <0.001). Therefore, testosterone treatment reduced the rate of new type 2 diabetes in at-risk men by 40%, beyond the effect of a lifestyle program. T4DM is the largest testosterone RCT completed to date, with a strongly positive result. There are caveats.

Key messages

T4DM was an Australia-wide twoyear randomised controlled trial of testosterone vs placebo for men with IGT or newly diagnosed T2DM Both arms had underwent a Weight Watchers program Abstract results from T4DM suggest testosterone may reduce rates of new type 2 diabetes in at-risk men, beyond that achieved by a community-based lifestyle program.

treatment with anti-obesity drugs or planned bariatric surgery, major cardiovascular event in the past six months, or active cardiac disease, systolic BP ≥160, diastolic BP ≥100, TIA or stroke within the previous three years, or any cancer other than non-melanoma skin cancer. All participating men received a free Weight Watchers program and were randomised to receive intramuscular testosterone undecanoate 1000mg at baseline, six weeks, and every three months thereafter, nine injections over the two-year intervention, or placebo, in double-blind fashion. Currently results are only available in abstract form. There were 1007 men randomised and 856 underwent the end-ofstudy OGTT. The numbers of men with two-year OGTT two-hour glucose ≥11.1 mmol/L were 55/443

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There were rigorous exclusion criteria. The effect of testosterone was studied on a background of a lifestyle program and may not be applicable to testosterone treatment given in isolation. A rise in haematocrit ≥0.54 was seen in 21.6% of men in the testosterone arm compared with 1.2% in the placebo arm (P<0.001), highlighting the need for careful medical supervision. At time of writing the T4DM primary outcomes paper had not yet been published, which needs to be done, before the findings can be fully discussed and then translated into practice. Meanwhile, men asking about testosterone and diabetes prevention, can be evaluated for co-morbidities such as obesity, sleep apnoea and depression, and for cardiovascular risk factors and disease. They can be encouraged to pursue healthy lifestyle behaviours. Obese men who successfully lose weight, reduce their risk of type 2 diabetes and often improve their testosterone levels. Interest generated by T4DM provides a valuable opportunity to advance men’s health. Men can be offered individualised assessments to improve their health outcomes, while T4DM’s implications are being considered. – References available on request Author competing interests – the author has received honoraria and research support from Bayer, Lilly and Lawley Pharmaceuticals, and honoraria from Besins and Ferring

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CLINICAL UPDATE

Colchicine & chronic coronary disease By Prof Peter Thompson & Dr Mark Nidorf, Cardiologists, Perth Colchicine is an ancient, yet sophisticated drug with multiple effects on cellular function involved with inflammation and healing. It has long held FDA approval for the lifelong treatment of Familial Mediterranean Fever and treatment and prevention of gout. There is growing evidence that the inflammatory process in atherosclerotic plaque occurs in response to crystallisation of cholesterol within the atherosclerotic bed. This raises the possibility that colchicine, which inhibits aspects of crystal-induced inflammation, may hold promise in the treatment of atherosclerosis. The LoDoCo2 trial demonstrated that colchicine 0.5mg daily was beneficial for patients with chronic (stable) coronary disease, over and above other proven secondary prevention therapies. Among controls, the risk of CV death, myocardial infarction, ischemic stroke or ischemia-driven revascularisation was 3.6% pa. In those on colchicine the risk was reduced by 31%, due mostly to its significant effect on myocardial infarction and ischemia-driven revascularisation. These effects emerged early and continued to accrue during five years of treatment. The results are consistent with the LoDoCo pilot and the COLCOT trial which showed that colchicine 0.5mg daily affords similar benefits to patients following a recent myocardial infarction. Long-term use of low-dose colchicine appears safe including in children, teenagers and during pregnancy and has no known effect on fetal development. It does not affect liver or renal function, cause or aggravate bleeding, lower blood pressure and is not pro-arrhythmic. Experience from strictly controlled clinical trials shows that colchicine 0.5mg daily compared to placebo does not appear to increase the risk of cancer, infection, neutropenia or myotoxicity even when used with full dose statins. Drug interactions other than with clarithromycin are also rare in the absence of renal impairment.

Key messages

Trails show low-dose colchicine to have benefit in secondary prevention Colchicine is inexpensive and well tolerated Approval is likely but currently this use is ‘off label’.

early side-effects, long-term use is well tolerated and associated with a significant improvement in diseasefree survival. Author competing interests – the authors participated in LoDoCo2

As with aspirin and statins, the longterm effects of treatment will need careful ongoing scrutiny.

Clinical implications It is likely that regulatory authorities will approve colchicine as a cornerstone treatment in patients with coronary disease alongside aspirin and statins. Currently its use for this purpose is ‘off-label’ and therefore a matter for the clinical judgement of the individual prescriber. If prescribing low-dose colchicine off-label for secondary prevention in patients with vascular disease, avoid using it in those with advanced renal disease (creatinine clearance <30ml/ min), known hematologic conditions with neutropenia or a requirement for clarithromycin, anti-fungal or anti-rejection therapy. A trial of low-dose colchicine comes at low cost and little risk. Intolerance is infrequent, usually mild and short-lived once therapy is ceased. Early side effects can be largely avoided by starting at 0.25mg before graduating to 0.5mg daily. For over 90% of patients without

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NOVEMBER 2020 | 45

Falls prevention in the elderly By Dr Joon Qing (Jason) Tan, Rehabilitation Physician, Murdoch Statistically, up to a third of people above the age of 65 have at least one fall annually. Fall and falls-related injuries result in significant morbidity and mortality in patients. In Australia, studies have shown that falls in the elderly is one of the commonest reasons for hospitalisation. Epidemiological data shows that falls account for up to 11% of community injury deaths. The adverse outcomes following a fall impose a significant cost to the health care system and contribute heavily to the overall burden of disease. The consequences of a fall vary in severity, from minor soft tissue bruising to catastrophic outcomes such as intracranial haemorrhage, fractures and death. Patients with falls suffer from lower functional outcomes, reduced confidence in their balance and increased level of anxiety.

Common causes One study showed that a “fall in the past 12 months” is the strongest single predictor of future falls. Polypharmacy increases the risk and frequency of falls, particularly drugs of the benzodiazepine and anti-depressant class. Psychotropic medications not only increase the risk of falling but is associated with

more injurious falls and falls-related mortality. These effects are augmented, particularly in the elderly due to increased CNS vulnerability and sensitivity to sedative effects. Anti-hypertensive related falls are not necessarily due to hypotension alone, but also the effects of dizziness, syncopal events and postural hypotension. Osteo-sarcopenia or frailty is an “age-related decline in skeletal muscle mass” and motor strength. The effects of age-related frailty lead to decreased strength, lower agility and slower motor reaction time. Functionally, this translates to a higher frequency of falls with ageing. Screening for these risk factors is vital in community practice. Tools that can be used are the Falls Risk Assessment and Management Plan (FRAMP), Falls Risk Assessment Tool (FRAT) and Hendrich Fall Risk Model. Various guidelines have been produced by the RACGP education series and the WA Department of Health to screen, assess and provide interventions to prevent falls in the community. In addition to a detailed medical history and clinical examination, a multidisciplinary

approach involving allied health professionals will form a holistic model in the prevention of falls in the elderly. Strategies to prevent and manage falls are medication review, rationalising and drug deprescribing, osteoporosis prevention, physiotherapy review (falls risk assessment, motor strengthening, balance training and gait retraining), occupational therapy review (functional assessment, mobility aids and customised equipment), dietician review (nutritional optimisation, including vitamin D supplementation), podiatry review (appropriate footwear, orthotics and specialised splinting), vision assessment and correction, continence assessment (i.e. continence nurse advisor), home safety assessment (hazard reduction +/- home modifications) and patient, family and caregiver education. There are many risk factors associated with falls, some are preventable and some from irreversible factors. As such, early identification of the risk factors is essential in the community to prevent hospital re-admissions and to improve overall quality of life. References available on request

Key messages

Most falls in the elderly are preventable A fall in the past 12 months is the strongest single predictor of future falls Use a multidisciplinary approach in the assessment and management of falls.

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CLINICAL UPDATE

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CLINICAL UPDATE

Radiation therapy and heart disease By Dr Benjamin King, Cardiologist, and Dr Tee Lim, Radiation Oncologist In mid-July 2020, a team of cardiologists and radiation oncologists became the first doctors in WA and the second in Australia to use stereotactic ablative body radiotherapy (SABR) to treat a heart disease patient. The team of Perth doctors carried out the procedure in close collaboration with Washington University of St Louis (WUSTL), where the technology was developed. SABR is a precise, targeted treatment that is most commonly used to treat cancer. It was utilised to treat a patient with ventricular tachycardia (VT). SABR delivers a high dose of precise radiation to kill tumours with minimal exposure to surrounding healthy tissue and allows areas of the heart responsible for serious arrythmias to be targeted. Stereotactic ablative radiation therapy for patients with VT is a relatively new concept and has only been carried out on about 80 patients worldwide and offers a viable non-invasive option for patients with cardiac arrhythmias who are too sick for invasive treatments or where other treatment options have been unsuccessful or inapplicable. It takes only between 10 and 20 minutes.

Key messages

Radiotherapy for treatment of heart disease is new

A case of VT has been treated in Perth

The procedure is non-invasive and takes under 20 minutes.

The VT burden remained high. Mechanical aortic and mitral valves and no pericardium made the left ventricle inaccessible for ablation.

A 54-year-old woman has mechanical mitral and aortic valves due to endocarditis and radical pericardiectomy for pericardial constriction. She had a presumed embolic inferolateral myocardial infarction occasioning moderate systolic impairment.

Echocardiography and cardiac CT (MRI ineligible) was performed for anatomic definition of the myocardial scar. The Cardio Insight body surface vest was then used to render the electrical activation data onto a CT representation of the heart. This technique identifies the areas of the myocardial scar that are critical to the maintenance of VT and therefore the target of (radio-) ablation.

From this scar, very frequent ventricular tachycardia was coming, resulting in frequent electrical storms, ICD shocks, and hospital admissions. Multiple co-morbidities disqualified her from transplant consideration. Further treatments including medication, CRTD and A-V node ablation, and stellate ganglion injection had minor beneficial effect.

The anatomic and electrophysiologic data was then used with the help of the WUSTL team to define the myocardial segments to target with radiotherapy. These segments were delineated on a respiratory-gated 4D planning CT and edited by the cardiology team to correspond to target areas. The radiotherapy team created a treatment plan that

Patient profile and outcome

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was reviewed independently and approved by colleagues in Perth and the WUSTL team. Stereotactic radiotherapy was delivered in a single 25 Gray fraction over 12 minutes. ICD tests before and after were performed, demonstrating no change in parameters nor noise detection. With the exception of expected minor lethargy, the patient has not suffered any side effects and has experienced no recurrence of sustained arrhythmia. In fact, she spent several weeks holidaying in the Kimberley over the winter. Cancer and heart disease are two of the biggest health burdens facing Australia so to find a treatment that is effective for both of these patient populations is a positive. – References available on request Author competing interests – the authors performed the procedure

NOVEMBER 2020 | 47

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CLINICAL UPDATE

Neuroprotective peptide ARG-007 (R18) in ischaemic stroke By Dr David Blacker, Neurologist, Hollywood A year ago, in Medical Forum, we outlined the progress at the Perron Institute in developing the neuroprotective peptide polyarginine-18 (R18; renamed ARG-007) for acute ischaemic stroke. Since then, there have been significant developments that suggest a major breakthrough is imminent. In February, our Canadian colleagues published the results of their phase III trial of the neuroprotective peptide, NA-1, also called nerinetide. The NA-1 trial randomised 1105 patients with acute ischaemic stroke to receive nerinetide or placebo, in addition to standard stroke care comprising endovascular thrombectomy, with or without thrombolysis, with tissue plasminogen activator (tPA). Overall, the results were neutral. However, in those subjects not receiving tPA there was a statistically significant reduction in infarct

Key messages

ARG-007 may be useful in combination with standard stroke care Recent trials have been encouraging Funding for clinical trials planned for 2021. volume, increased chance of a good outcome and lower risk of death. A pharmacokinetic sub-analysis suggested plasmin, the proteolytic enzyme activated by tPA, was degrading nerinetide, rendering it ineffective. Experiments by the team at Perron Institute have consistently found ARG-007 to be superior to NA-1, and critical new data has demonstrated that the D-enantiomer of ARG007 (i.e. peptide synthesised with

D-arginine as opposed to L-arginine) to be resistant to degradation by plasmin. This has important implications for ARG-007 to be potentially a much more useful drug when used in combination with standard stroke care. This, together with recent encouraging immunotoxicity safety data, has further accelerated the work leading up to a first in-human trial of ARG-007, which will probably occur in the first half of 2021. A pre-clinical drug development bio-tech company, Argenica Therapeutics (argenica.com.au), has been formed to fund the next stages of development. The goal is to list the company on the ASX in March 2021 which should generate funds to support clinical trials of ARG-007. Author competing interests – the author is an advisor to and shareholder in Argenica Therapeutics

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NOVEMBER 2020 | 49

Low haemoglobin in the elderly – physiological or pathological? By Dr Benedict Carnley, Pathologist, Perth The World Health Organisation suggests normal haemoglobin is above 120 g/l in females and 130 g/l in males. Notwithstanding minor differences in reference ranges used by different laboratories because of different testing platforms, up to 26% of males and 20% of females older than 85 will be anaemic based upon the WHO diagnostic thresholds. It is likely this number will increase into the future. Anaemia is an independent risk factor for the development of cognitive impairment and reduced executive function. Impaired mood, reduced quality of life and an increased risk of falls and fractures have all be associated with anaemia in the elderly. Even mild anaemia, may be a prognostic marker associated with an increased overall mortality when adjusted for compounding factors such as chronic inflammation and chronic renal disease. Development of anaemia in the older patient is often due to multiple causes including nutritional deficiencies, blood loss, inflammation and chronic renal disease and the presence of

low-grade clonal disorders (e.g. myelodysplasia or chronic leukaemia or lymphoma). In any given individual, a combination of these causes may lead to reduced haemoglobin levels or blunted responses to erythropoietin and a direct negative impact on erythropoiesis and disordered regulation of iron metabolism. Reduced iron stores are the most frequent nutritional deficiency leading to anaemia in the elderly. Gastrointestinal bleeding, possibly exacerbated by anticoagulation therapy, may cause iron deficiency and represents an initial diagnostic consideration. Malnutrition resulting from social isolation, disordered gastrointestinal function and poly-pharmacy may also contribute to reduced iron stores. Pernicious anaemia is relatively rare, however, extended use of acid-reducing medications or atrophic gastritis, may lead to vitamin B12 deficiency. Folate deficiency complicating anticonvulsant or methotrexate therapy and from alcohol excess should be considered.

Anaemia of inflammation and anaemia of chronic kidney disease are common in older patients. A pro-inflammatory state may be age-related in some patients and may be accompanied by changes in haematopoeisis (clonal haematopoeisis of indeterminate potential – CHIP). Development of clonal heamatopoietic disorders is common in older individuals and myelodysplastia should be excluded in patients presenting with both unexplained anaemia and other cytopenias. The diagnostic approach should include basic investigations including full blood count, reticulocyte count, iron, vitamin B12 and folate studies, erythropoietin level, assessment of renal function, inflammatory markers, liver function tests and assessment of serum protein electrophoresis. This helps to exclude nutritional deficiencies and identify inflammatory states. Specialised investigations including endoscopy and bone marrow examination may be required. Bone marrow examination may continued on Page 51

Professor Richard Naunton Morgan — General Surgeon MBBS FRCS AMC FRACS

South Perth Hospital is pleased to advise Professor Richard Naunton Morgan, General Surgeon, has commenced a General Surgical service. Professor Naunton Morgan consults at 72 South Terrace, South Perth. Consultation bookings: 0466 342 100 Postal address: PO Box 214, Como WA 6952 Professor Naunton Morgan and his anaesthetist are no gap providers.

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CLINICAL UPDATE

Who will make the call? ‘Goals of Patient Care’ is helping By Dr Kevin Yuen, Palliative Care Consultant, Perth GOALS OF PATIENT CARE XY000240

GOPC aims to match a person’s illness and goals with what the hospital system has to offer An Advance Health Directive or Advance Care Plan assists hospital teams to complete Goals of Care Open, compassionate discussions are making ‘the call’ less difficult.

UMRN

First Name

DOB

Gender

Address

Postcode

Dr / Consultant:

SECTION 1 BASELINE INFORMATION

Primary illness: Significant co-morbidities: In the event that the patient is unable to speak for themselves, who would they wish to speak for them? This is known as the ‘Person responsible’ Name: Relationship: Does the patient have?: Yes No * Advance Health Directive (AHD) Yes No * Advance Care Plan (ACP) Yes No * Enduring Power of Guardianship (EPG) EPG contact name: Phone: Yes No * Does the patient have a registered organ donation decision? Yes No * Are the family aware of the patient’s donation decision? Designation: Clinician’s Name (please print): Date: / / Time: Signature:

SECTION 2 GOAL OF CARE

Please tick one only and complete section 3 over the page to be valid. In discussion with the clinician, patient, person responsible and/or family/carer(s), please select the most medically appropriate agreed goal of patient care that will apply in the event of clinical deterioration.

All life sustaining treatment * For Rapid Response (MER/MET Calls) * For CPR * For ICU

Life extending intensive treatment – with treatment ceiling

Our approach is changing We received a referral from ED to see an elderly lady, in poor general condition, with dementia and recurrent pneumonia. The son desperately hoped his mother would recover with our ‘good’ treatment. While a trial of antibiotics had been

GOPC is a hospital-driven process trying to match a person’s illness and goals with what the hospital system has to offer. It can be guided by the Advance Health Directive (AHD) or Advance Care Plan (ACP). Do you have one? If not, how will we know

MR00H.1 07/17

* Not for CPR

* * * * *

For Rapid Response For ventilatory support, including intubation Specify maximum level of support For ICU/HDU admission

Yes Yes

No No

Yes

No

Additional comments (e.g. use of inotropes, NIV, dialysis)

Active ward based treatment – with symptom and comfort care * Not for CPR * Not for ICU * Not for intubation

* * * *

For Rapid Response For ventilatory support (intent is symptom control) Specify maximum level of support

Yes Yes

No No

Additional comments (e.g. use of antibiotics, IV fluids)

Optimal comfort treatment – including care of the dying person * Not for Rapid Response * Not for CPR * Not for intubation * Not for ICU

* For ongoing review to identify transition to the terminal phase * Ensure timely commencement of the Care Plan for the Dying Person

All patients can have Rapid Response based on ‘Worried Criteria’ or to ‘Summon Clinical Review’.

MRALERT00H.1 HCCZZFMR00H1.indd 1

12/07/2017 2:29 PM

how much treatment you may or may not want? Thankfully more realistic, open, compassionate discussions are happening and making ‘the call’ is becoming less difficult. As we try to best traverse the life-and-death decision zone, clarity, honesty and a compassionate approach are essential travelling aids. Author competing interests – nil

Low haemoglobin in the elderly continued from Page 50 provide significant diagnostic, prognostic and treatment guiding information, while being a relatively straightforward procedure associated with limited pain and discomfort.

Therapy aiming to improve haemoglobin levels seeks to address the underlying cause while also restoring haematopoiesis. Therapeutic options include oral or parenteral iron therapy, vitamin B12 replacement and the use of erythropoietin stimulating agents.

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GOALS OF PATIENT CARE SUMMARY TRIAL

started, the ED doctor discussed in a compassionate, considered way that the outlook was poor, and the likely outcome was that his mother would die in the next few days. He completed a Goals of Patient Care (GOPC) form, ticking the ‘Optimal comfort care’ option, which her son accepted. GOPC is a form and a process. We used to complete a ‘Not for Resuscitation’ form for patients we did not think would benefit from CPR or intensive treatments. Now we are getting better at understanding and accepting what are the probabilities of success from our treatments especially with our frail patients. GOPC allows us to discuss these probabilities with our patients and their families and discover what their expectations and care preferences might be.

We could recover many patients but not always to their former baseline. Many would be back in ED a few weeks later in a similar or worse condition. Often for those who survived there would be a significant amount of additional suffering: a diminished functional level, an increased symptom burden, social dislocation.

Ward:

Family Name

MR00H.1

In the past with our ‘can do, should do attitude’ we would actively treat all who came our way. Usually this was with the family urging and supporting this approach. The outcomes were mixed.

Hospital:

DO NOT WRITE IN MARGIN

As a palliative care consultant at RPH, I’m regularly seeing elderly patients present to our Emergency Department (ED) with life threatening conditions and the dilemma facing us all is ‘to treat or not to treat’.

Key messages

ESCALATION PLAN

You’re getting older…maybe your heart or lungs aren’t working like they used to. Perhaps your brain is beginning to forget things. As you stride or stumble past 70 life will be become more fragile. If you suffer a significant medical happening – a heart attack, a stroke, a pneumonia – who will make the call as to what treatment we should offer you?

HCCZZFMR00H1

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CLINICAL UPDATE

Disease-modifying therapies may be indicated in some clinical scenarios. Effective therapy can potentially improve haemoglobin leading to increased quality of life and reduced morbidity in older patients with anaemia. – References on request NOVEMBER 2020 | 51

Expert imaging plays an integral part in today’s multi-disciplinary approach to disease management. It’s our sub-specialty trained radiologist philosophy that ensures an appropriate expertise is available in every case.

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WINE REVIEW

Chateau Tanunda Chateau Tanunda has produced wines for 130 years and has survived by changing with the times but keeping the traditions of the Barossa intact. Seeing the opportunity created by the phylloxera plague in Europe, the owners built the largest winery in the southern hemisphere to supply a wine-starved Europe. Even now, with new owners, the challenge of making wines for a new generation of consumers has led to bold decisions and innovative wines. I received a portfolio of four reds that cover the breadth of what both new and old vineyards can offer in the tapestry of the Barossa.

2018 Chateau Single Vineyard Cabernet Sauvignon Single vineyard wines tell drinkers a lot about terroir and this wine is all Eden Valley, cool climate Cabernet. Made in the same way with minimal intervention, basket pressing, 18 months of oak and unfiltered. A wine style for newer red wine drinkers with subtle aromas of cedar, eucalyptus and blackcurrants. The cooler climate fruit is balanced by silky tannins and although still a young wine it carries a lot of finesse. Old techniques matched with a modern twist.

Review by Dr Martin Buck

2018 Grand Barossa Shiraz

2018 Greenock Shiraz

This is a bistro-style Shiraz sourced from around the region. It has been basket pressed after a week on skins and then aged in oak for 18 months. There are aromas of berries and spice with a restrained palate of subtle fruit, soft tannins and a delicate finish. This is a very good value wine and way above its price point. Best drinking now but will cellar in the short term.

This wine is part of the Icon of the Barossa series and is exclusively sourced from the most western of the Barossa parishes. A wine with a lot of tradition using small batches, gentle basket extraction and open fermenters to enhance the shiraz flavours. Lifted herbal aromas with mulberries lead into a Christmas cake of spicy flavours. A full-bodied palate with intensity, balance and depth – Old Barossa in a glass. This wine will age beautifully and gain complexity.

The Whole Dam Family 2017

S WER' E I V RE

K C I P

This wine pays homage to the great French wine varieties that have made their home in the Barossa. Predominately hand-picked Grenache and Shiraz with Carignan, Cinsault and Mouvedre included for complexity and body. Parcels of fruit are treated individually, basket pressed, aged in oak and then assembled to ensure a complex wine. Smouldering fruit aromas lead into an intense berry palate with spice and plums. This was my favourite due to its depth and intensity.

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NOVEMBER 2020 | 53

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