How this list was developed
In 2016, three Fellows from ANZPM/AChPM convened a working group to produce an EVOLVE list for palliative medicine. The RACP Policy & Advocacy Unit assisted this working group in compiling a list of 15 clinical practices which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas.
An email was then sent out to all ANZPM and AChPM members with this list seeking feedback, and whether any items should be omitted and/or what new items should be added to this list. 40 responses to this email were received. Based on these responses, an online survey was prepared containing a list of 12 of the original 15 practices. The survey asked respondents to rate each practice against three criteria from 1 (lowest) to 5 (highest) as well as to nominate any additional practices worthy of consideration. The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question.
Based on the results of this survey which had 114 respondents, the top 5 were selected.
As evidence and clinical practice advances, Evolve recommendations will reflect these changes following a review. The latest SOMANZ recommendation developments are outlined below.
Removal of recommendations 2019
In 2019 following a review of priorities by the Chapter Committee, recommendations 2 and 4 were substituted with new recommendations to add more specialist physician specific recommendations to the list. The list was then duly consulted with all internal and external stakeholders with an interest and expertise in the subject matter of the new recommendations.
Original recommendation 2: Do not delay conversations around prognosis, wishes, values and end of life planning (including advance care planning) in patients with advanced disease
Advance care planning is a process, which includes choosing a surrogate or alternate decision maker and communicating values or wishes for medical care. Evidence shows that advance care planning conversations improve patient and family satisfaction with care and concordance between patients’ and families’ wishes, reduce the likelihood of unnecessary hospital care and increase the likelihood of receiving hospice care.
Supporting evidence
Original recommendation 4: Do not use percutaneous feeding tubes in patients with advanced dementia; instead use oral assisted feeding
Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhoea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.
Supporting Evidence
- Teno JM. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012; 172(9): 697-701
- Hanson LC. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc 2011; 59(3): 463-72
- Sampson EL. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009; 2:CD007209
- Finucane TE. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999; 282(14): 1365-1370