RACGP KFP 2017.2.22 – Indigenous Palliative Care

RACGP KFP 2017.2 Case 22 sees an encounter with Grace, a 68 year old indigenous woman who has recently self-discharged from your rural GP-run hospital where she was being provided palliative care for advanced cerebral glioblastoma. She was removed by her family due to concerns about her care.

What difficulties may be encountered when delivering a diagnosis and prognosis relating to end of life care? (List 3)

Reluctance of family to acknowledge bad news
Time required to discuss information required
Integration of cultural beliefs into the consult

From Queensland Health – Sad News, Sorry Business

The patient and their family may be reluctant to acknowledge bad news or may not understand what it immediately means for themselves or their kin.

The patient and their family may need time to discuss the information to gain a complete understanding for all involved.

Some Aboriginal and Torres Strait Islander people maintain their cultural beliefs, which is inclusive of spiritual beliefs about the causes of poor health. These beliefs generally may conflict with Western explanations and diagnosis of illnesses.

From the An introduction to Aboriginal and Torres Strait Islander health cultural protocols and perspectives

Deceased people: Where they exist, it is important to follow Aboriginal or Torres Strait Islander protocols for the avoidance of naming deceased people. Protocols differ across the country. Where necessary, consult the local community for correct procedures, avoidance names, time periods for avoidance and the use of images and naming of deceased people.

A death in a community The question on how to deal with members of a community who have passed away can be a significant issue. Death and ‘sorry business’ is a continuous cycle that impacts greatly on communities. Culturally, it is difficult for some family members to mention the deceased person by name. It is best to contact the local Aboriginal health service or land council to liaise with a family member, rather than go to family members directly while they are grieving.

In some Aboriginal or Torres Strait Islander communities, the entire community will shut down for sorry business following the death of a member. As a result,it is advisable to contact communities before leaving for a scheduled meeting to make sure that they are able to conduct formal business. Many communities have a mourning period where that person’s name and image cannot be used.

The time of mourning is different between communities. It can be for a week, a year or an indefinite period of time, during which you will not be able to use the name, image, voice or video of the deceased.

What are the elements of building rapport in this situation? (list 3)

Be respectful of cultural requirements
Display honesty
Be proactive in orientation and explanations

From Queensland Health – Sad News, Sorry Business

Be respectful of the patient’s cultural requirements and ask questions about their culture. Mutual respect and reciprocity is a common cultural value for Aboriginal and Torres Strait Islander people.

Be honest.

Be proactive in providing orientation and clear and simple explanations for treatments and daily routines, e.g. why procedures have been postponed or cancelled, where the patient kitchen is, where waiting areas are located etc.

What aspects of the arrival of family, directly before patient passing, should be considered? (list 3)

Consider larger room for patient and family
Consider extending visiting hours
Consider on-site accomodation

From Queensland Health – Sad News, Sorry Business

Consider providing a larger private room for the patient.

Due to the distance from possible remote and interstate locations that family members will travel from, special considerations for visiting hours should be factored in for an Aboriginal or Torres Strait Islander patient.

A family member may request to stay overnight with the patient. When allocating patients, consider how you can accommodate this request.

Develop rapport and work with the family. This is very important in providing the best care possible to the patient, ensuring cooperation and mutual understanding.

Anticipate many questions. Some people may however be very quiet; they may have many questions to ask but may be shy or intimidated and not know how or what to ask.

With the consent of the patient and/or their family, ensure the involvement of the Aboriginal and Torres Strait Islander Hospital Liaison Officer or Health Worker in caring for the patient.

Some Aboriginal and Torres Strait Islander families may request a visit from the clergy or chaplain. Ensure that you have chaplain support services information readily available.

Refer the family to a local Aboriginal and Torres Strait Islander social and emotional well-being organisation, if possible.

RACGP Feedback – Case 22

This case focused on the end-of-life care for a female Aboriginal patient with a high-grade glioblastoma. The patient’s family had chosen to remove her from the hospital due to concerns about her care. The questions focused on the key issues that need to be addressed both initially and as the patient’s condition deteriorates, taking into context her cultural, social and medical needs.

The common error in this question was to not read the scenario and identify the support that was already in place in the form of family, community and Aboriginal health workers, and provide these all as a ‘rote list’ without considering the information. No mark was given for repeating information given in the case scenario.

Other common errors included candidates listing reasons as to why the patient’s care may not have been appropriate in hospital and the issues of that environment, rather than those faced in the home environment. This reinforces the need to carefully read the case and its questions.

RACGP Conclusion on Technique

As outlined above, there are some common themes and key issues to consider when approaching the KFP exam:

The KFP exam is not a simple short-answer paper. You must answer the question in the context of the clinical scenario provided, utilising all of the information provided. Read the scenario at least twice.
Keep your answers succinct.
Only provide the number of answers requested. Review your answer – have you created a list rather than one answer per line? If so, you will be penalised for extra answers.
Always read the question at least twice and, after you answer, check that you have answered the actual question asked.
Be specific in your answers, whether in the investigations being ordered or the treatment you are prescribing. Non-specific answers will not score or will attract a much lower score.
General answers such as ‘educate’, ‘refer’, ‘reassure’ or ‘review’ do not score without specific detail. For example, providing a review timeline and details about the specialist to whom you are referring (along with degree if urgency, if appropriate) may score marks if relevant to the scenario and question.
Be aware of clinical guidelines and any important changes or additions to treatments. If guidelines change very close to the exam, the marking keys are adapted to consider the original and the new guidelines so candidates are not penalised if they have not seen a guide published close to the exam sitting.
Access the practice exams provided after enrolment closes and utilise the RACGP assessment resources provided for candidates.

RACGP KFP 2017.2.22 – Indigenous Palliative Care

What difficulties may be encountered when delivering a diagnosis and prognosis relating to end of life care? (List 3)

What are the elements of building rapport in this situation? (list 3)

What aspects of the arrival of family, directly before patient passing, should be considered? (list 3)

RACGP Feedback – Case 22

RACGP Conclusion on Technique

References

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