Holistic practice and excessively thorough paperwork: A response to Julião et al.

Dear Editor,

We read Julião et al.'s recently published paper (Julião et al., 2020) with interest. Our experiences, working in palliative care services in the UK, are consistent with the authors’ findings of more limited documentation of psychosocial than physical needs in initial palliative care assessments. This may result from the ongoing primacy of the medical model, even in palliative care settings where holism is promoted. In an attempt to drive a comprehensive holistic needs assessment, many palliative care services have developed detailed paperwork to support clerking on admission to an inpatient unit. While this may be particularly useful as an aide-memoire for junior staff and those less familiar with the holistic approach of palliative care, it is our experience that, in practice, psychosocial needs are frequently dxeprioritized due to the existing culture of emphasizing the exploration of physical symptoms. Additionally, given the ubiquity of fatigue in patients with palliative care needs (Mücke et al., 2015), comprehensiveness of information gathering at an initial meeting must be balanced against the risk of exhausting the patient. Over-emphasis on thoroughness at a first meeting risks sapping the patient's energy and goodwill and often it is the psychosocial issues that are initially explored to a lesser degree.

The limited amount of existing evidence concerning the impact of admission paperwork on clerking outcomes focuses on efforts to increase thoroughness through the use of proformas (Chow et al., 2014; Ehsanullah et al., 2015; Smallwood et al., 2018), demonstrating increased completeness when proformas are used, but with no measurement of patient-centered impact or outcomes. While some prompts are undeniably useful, holism may at times be discouraged by overly prescriptive paperwork that aims for absolute thoroughness.

We propose that if holistic needs assessment education was embedded at an earlier stage of clinical experience, particularly undergraduate medical training, organizations would be able to place greater reliance on the judgement of their staff, including non-specialist junior doctors. This could result in redesign of clerking paperwork to emphasize holistic practice and patients’ needs, rather than rigid tools designed around healthcare professionals’ agendas. Doctors would have the skills to recognize patients’ level of fatigue, enabling them to prioritize initially obtaining the information needed to enable them to address individual patients’ main priorities and most pressing needs, while also practicing safely. Subsequent consultations would allow the multidisciplinary team to “fill in the gaps”. This would avoid the imposition of institutionally predetermined priorities, mediated through having to meet the needs of a proforma, interfering with a genuinely patient-led initial clerking consultation.

Paperwork can and should encourage holistic practice, although for safety-minded organizations, taking a leap away from inflexible and prescriptive paperwork is challenging. Widespread implementation of early education about patient-centered consultations, reinforced through supervised early practice, would enable this leap to be successful and patient care to be ultimately more holistic.