Dr David Cameron has been involved in the care of people with advanced serious illnesses over the past 30 years. These patients face many challenges, including unpleasant symptoms and a significant loss of independence. They need increasing help with their daily activities. They also face an uncertain future with regards to recovery or further decline and a premature death.
Managing such illnesses requires more than a diagnosis, it requires a comprehensive view of the person and of their family. It involves effectively managing symptoms, identifying unmet needs and then coordinating available professional resources.
The term palliative care has been used to describe this approach to serious illnesses. In order to
understand this better, consider the difference between tennis and football. In tennis you have one
opponent and your task is to beat him. In football you have a team and you are faced with multiple
opponents and multiple decisions. To win at football you need to work as a team to out manoeuvre your enemy. Communication and teamwork are key to success in football as well as palliative care.
Alignd discussed palliative care in the South African context with him.
Alignd: Where does palliative care currently sit in South Africa and globally?
Dr. Cameron: Palliative care has been recognised by the World Health Organisation (WHO) as a global
health priority. South Africa is a signatory to the resolution adopted by the World Health Assembly in 2014. Yet seriously-ill South Africans in general have little choice in how they want to live their final
months of life. It is well known that patient care at the end-of-life is complex and expensive, yet current structures within local medical scheme benefits limit access to appropriate patient-centred palliative care. This is out of sync with the realities of palliative care internationally when looking at countries such as the USA, Canada and Australia.
Current contract mechanisms and benefit design do not incentivise team-based care within the
community. In patients with progressive chronic illnesses this results in frequent hospitalisation and
fragmentation of care. There is little advanced health care planning and preparing patients and families regarding the natural course of most serious illnesses.
Alignd: How would you describe the needs of the patient in this situation?
Dr. Cameron: Studies have shown that most people would like to die peacefully at home with their
loved ones, not at a hospital linked up to tubes and machines. Facing death is a frightening and complex challenge for most people.
Hence patients need to be managed holistically, including consideration of their symptoms, their
emotional and spiritual needs and the needs of their families. They also need their doctors and
caregivers to be accessible. However, the number of South Africans with advanced illnesses who die in
hospitals exceeds internationally accepted norms.
Alignd: What about costs?
Dr. Cameron: Healthcare costs in the last year of a patient’s life are more than three times higher than
in the second last year of life. Recent estimates are that medical schemes spend close to R12-billion on
health care for those patients who are in their last year of life. We need to assign costs differently when it comes to palliative care. I can spend an hour and a half on a consultation with a terminally ill patient.
Clearly a fee-for-service model, which compensates on the basis of a 15-minute consultation, is not
appropriate for the realities of palliative care
Alignd: How does a value-based care model address this situation?
Dr. Cameron: Value-based care looks at outcomes, rather than activity and cost. It involves an
interdisciplinary team of practitioners, which combine to address the clinical, physical, psychosocial and spiritual needs of the patient, enabling optimal quality of life when facing serious illness. It rewards team members according to outcomes rather than activities.
Value-based care also avoids, where possible, unnecessary medical interventions and hospitalisation
and focuses on quality care, family involvement, symptom alleviation, incorporation of a number of
experts in various fields and the wishes of the patient, which usually involve being treated at home with loved ones close by. For the medical scheme, the result is more predictable, with a defined end-point, rather than an open-ended, costly process. The current “fee-for-service” system encourages doctors to over service
Alignd: In closing, despite all the challenges, why have you chosen to focus on the care of the
terminally ill?
Dr Cameron: It is a real privilege to accompany seriously ill people on their final journey. Bringing
comfort, calmness and care in the midst of turmoil, pain and fear is very rewarding. A peaceful, dignified death in the comfort of one’s own home, is something that can be achieved for more than 80% of dying people. Perhaps I can end off with a short account of a dying patient I met in a rural village about 15 years ago.
Flies circle like lazy vultures parting the air
saturated with the smell of cervical cancer.
Too weak to sit up, she reached out and grasped my hand,
33 degrees outside, it felt like 40 under the low tin roof.
“Hospital?” I suggested. “No, people die there.”
Six pairs of weary eyes watch my every move.
