Special not different: general practitioners' accounts of their care of dying people

Long-term effects of an undergraduate palliative care course: a prospective cohort study in El Salvador

BACKGROUND

International organisations recommend the inclusion of palliative care undergraduate education as a way to meet increasing demand; the long-term effects, however, are unknown. Since 2013 the Dr José Matías Delgado University has offered an undergraduate course for palliative care.

AIMS

To assess whether a palliative care course results in improvement in self-perceived comfort among students and if it lasts up to 4 years later; and to examine students' knowledge of palliative care and assess the relationship between comfort and knowledge.

DESIGN

This is a prospective cohort study where students attending the course were requested to complete the Scale of Self-Perceived Comfort in palliative care pre and post course. Participants were contacted in 2018 and a group without palliative care education was established as a control group, matched one-to-one according to current academic level. They were asked to complete the Scale of Self-Perceived Comfort questionnaire together with the Palliative Care Knowledge Test.

SETTINGS/PARTICIPANTS

83 students who attended the course between the years 2014 and 2017 and 101 controls.

RESULTS

In the postcourse test, participants had a 1.13-point increase (p≤0.001) in comfort, which persisted 4 years later and was superior to the control group by 0.6 points (p≤0.001). The control group showed no difference in the precourse test despite having more clinical experience (p=0.68). The students outscored the control group in the knowledge test by 4.2 points (p≤0.001). There appears to be no correlation between comfort and knowledge.

CONCLUSION

A palliative care undergraduate course results in improvement in student comfort and knowledge which persists up to 4 years later.

How Primary Care Clinicians Process Patient Death: Logistics, Emotions, and Opportunities for Structural Support

BACKGROUND

Navigating the logistics and emotional processing of a patient's death is an inevitable part of many physicians' roles. While research has primarily examined how inpatient clinicians cope with patient loss, little work has explored how primary care clinicians (PCCs) handle patient death in the outpatient setting, and what support resources could help PCCs process loss.

OBJECTIVE

To explore PCCs' experiences with the logistics and emotional processing of patient deaths and suggestions for supportive resources.

DESIGN

Qualitative study using semi-structured interviews conducted between March and May 2023.

PARTICIPANTS

Recruitment emails were sent to 136 PCCs (physicians and nurse practitioners) at three San Francisco academic primary care clinics. Twelve clinicians participated in the study.

APPROACH

This study used a template analysis approach. Interview transcripts were analyzed in an iterative fashion to identify themes for how PCCs navigate patient death.

RESULTS

Participants (n=12) described outpatient death notification as inconsistent, delayed, and rife with uncertainty regarding subsequent actions. They felt various emotions, notably sadness and guilt, especially with deaths of young, vulnerable patients or those from preventable illnesses. Participants identified strategies for emotional processing and recommended improvements including clear procedural guidance, peer debriefings, and formal acknowledgements of deceased patients.

CONCLUSIONS

Interviewing PCCs about their experiences following a patient death revealed key themes in logistical and emotional processing, and clinic resource recommendations to better support PCCs. Given the distinct characteristics of primary care-such as enduring patient relationships, greater isolation in ambulatory settings compared to inpatient environments, and rising burnout rates-enhancing guidance and support for PCCs is crucial to mitigate administrative burdens and grief after patient loss.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study

BACKGROUND

Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients.

METHODS

We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis.

RESULTS

Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP.

CONCLUSION

GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Supporting bereavement and complicated grief in primary care: a realist review

Background

Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients.

Aim

To identify what works, how, and for whom, in the management of complicated grief (CG) in primary care.

Design & setting

A review of evidence on the management of CG and bereavement in UK primary care settings.

Method

A realist approach was taken that aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes.

Results

Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time, and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients’ needs can encourage a proactive response and help identify appropriate support.

Conclusion

Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients.

A Qualitative Study on the Experiences and Reflections of Junior Doctors During a Palliative Care Rotation: Perceptions of Challenges and Lessons Learnt

CONTEXT

Doctors caring for patients with life-limiting illness are often exposed to emotional distress.

OBJECTIVES

We aimed to explore the experiences and perceptions of junior doctors working full time in a palliative care rotation. We examined the lessons junior doctors learnt in managing their emotions as they face patients' death on a daily basis.

METHODS

We conducted a qualitative study with seven focus group discussions involving 21 junior doctors (medical officers and residents). Data were analyzed using qualitative thematic analysis to identify the themes related to the perceived challenges of these junior doctors and how they managed the struggles. Interviews were conducted with junior doctors who spent at least two months in a palliative care unit in a tertiary hospital or an inpatient hospice.

RESULTS

Junior doctors caring for dying patients in a palliative care rotation faced internal conflicts. Conflicting feelings arose because of differing expectations from their preconceived notions of their roles as doctors. Two main themes of internal struggles were professional distancing and emotional detachment as well as prognostic uncertainty and when to withhold and withdraw medical treatments. Coping strategies that helped included mentoring and role modeling provided by palliative care physicians, reframing their care experiences and reflection to find meaning in their work.

CONCLUSION

A palliative care rotation exposes junior doctors to emotionally overwhelming experiences. With proper guidance, this exposure is useful in teaching junior doctors important coping strategies, allowing learning to occur at a deeper level.

Student's Inventory of Professionalism (SIP): A Tool to Assess Attitudes towards Professional Development Based on Palliative Care Undergraduate Education

Introduction: Quality medical education, centered on a patient's needs, is crucial to develop the health professionals that our society requires. Research suggests a strong contribution of palliative care education to professionalism. The aim of this study was to design and validate a self-report inventory to measure student's professional development. Method: Sequential exploratory strategy mixed method. The inventory is built based on the themes that emerged from the analysis of four qualitative studies about nursing and medical students' perceptions related to palliative care teaching interventions (see Ballesteros et al. 2014, Centeno et al. 2014 and 2017, Rojí et al. 2017). The structure and psychometrics of the inventory obtained is tested in two different surveys with two different groups of medical students. Inventory reliability and construct validity are tested in the first survey group. To verify the inventory structure, a confirmatory factor analysis is performed in a second survey group. Results: The inventory has 33 items and seven dimensions: a holistic approach, caring for and understanding the patient, personal growth, teamwork, decision-making, patient evaluation, and being a health care professional. Cronbach's-alpha was 0.73-0.84 in all seven domains, ICC: 0.95. The confirmatory factor analysis comparative fit index (CFI) was 1 with a standardized root mean square Index 0.088 (SRMR) and obtained a 0.99 goodness-of-fit R-square coefficient. Conclusions: this new inventory is grounded on student's palliative care teaching experiences and seems to be valid to assess student's professional development.

Palliative care teaching shapes medical undergraduate students' professional development: a scoping review

PURPOSE OF REVIEW

The aim of this review is to understand how palliative care teaching (PCT) as a patient-centered learning model, influences medical undergraduate students' professional development.

RECENT FINDINGS

To study PCT medical undergraduate students' learning experiences, we have employed the medical teaching concept, 'hidden curriculum,' as a way of describing attitudes and behavior conveyed implicitly by palliative care educators. Fifteen studies were selected: ten of those studies used a qualitative approach; two are theoretical explanations of the topic explored, one guideline, one review and just one quantitative study, made up the review. Medical undergraduate students reported that after PCT, they felt they had acquired better attitudes for effective integration with the patient, such as empathy or holistic care; ethical principles, such as respect or humanization of their clinical practice; and commitment to an improvement in competences, such as self-awareness or self-esteem. They also reported improved behavior in effective integration with patients, such as communication, caring for patients' families, and when addressing psychosocial, cultural and spiritual aspects; their commitment to improvement in competences, such as dealing with emotions and uncertainty; they learned team work as an effective way to interact within the health system; and to become more reliable, making themselves more available and dedicating enough time to each patient.

SUMMARY

PCT seems to be an effective way of fostering medical undergraduate students' patient-centered professional development.

Teamwork in primary palliative care: general practitioners' and specialised oncology nurses' complementary competencies

BACKGROUND

Generalists such as general practitioners and district nurses have been the main actors in community palliative care in Norway. Specialised oncology nurses with postgraduate palliative training are increasingly becoming involved. There is little research on their contribution. This study explores how general practitioners (GPs) and oncology nurses (ONs) experience their collaboration in primary palliative care.

METHODS

A qualitative focus group and interview study in rural Northern Norway, involving 52 health professionals. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.

RESULTS

The ideal cooperation between GPs and ONs was as a "meeting of experts" with complementary competencies. GPs drew on their generalist backgrounds, including their often long-term relationship with and knowledge of the patient. The ONs contributed longitudinal clinical observations and used their specialised knowledge to make treatment suggestions. While ONs were often experienced and many had developed a form of pattern recognition, they needed GPs' competencies for complex clinical judgements. However, ONs sometimes lacked timely advice from GPs, and could feel left alone with sick patients. To avoid this, some ONs bypassed GPs and contacted palliative specialists directly. While traditional professional hierarchies were not a barrier, we found that organization, funding and remuneration were significant barriers to cooperation. GPs often did not have time to meet with ONs to discuss shared patients. We also found that ONs and GPs had different strategies for learning. While ONs belonged to a networking nursing collective aiming for continuous quality improvement, GPs learned mostly from their individual experience of caring for patients.

CONCLUSIONS

The complementary competences and autonomous roles of a specialised nurse and a general practitioner represented a good match for primary palliative care. When planning high-quality teamwork in primary care, organizational barriers to cooperation and different cultures for learning need consideration.

Community Hospitals: an Under-Recognized Resource for Palliative Care

In the UK there are concerns that, in certain groups of dying patients such as the old, those with non-cancer diagnoses and those in rural areas, the quality of care is unacceptably variable. There has been no systematic survey of the extent to which community hospitals provide general palliative care for such patients. Therefore, by means of a structured questionnaire we asked senior nurses/managers at all 478 community hospitals in the UK for information on staff expertise, facilities and specialist equipment, liaison arrangements with specialist palliative care providers, priorities, practice and policy in end-of-life care. Of the 346 hospitals (72%) that responded, only 28 were in urban areas. 73% of hospitals employed at least one nurse with additional training in palliative care, 72% had access to 24-hour specialist palliative care advice and 51% had separate overnight accommodation for relatives, but only 22% had designated palliative care beds. Most hospitals did not have written policies or guidelines for patient assessment or symptom control. These findings add to evidence that community hospitals represent an important resource to improve access to palliative care for groups that are currently under-served.

Primary care physicians' educational needs and learning preferences in end of life care: A focus group study in the UK

BACKGROUND

Primary care physicians (General Practitioners (GPs)) play a pivotal role in providing end of life care (EoLC). However, many lack confidence in this area, and the quality of EoLC by GPs can be problematic. Evidence regarding educational needs, learning preferences and the acceptability of evaluation methods is needed to inform the development and testing of EoLC education. This study therefore aimed to explore GPs' EoLC educational needs and preferences for learning and evaluation.

METHODS

A qualitative focus group study was conducted with qualified GPs and GP trainees in the UK. Audio recordings were transcribed and analysed thematically. Expert review of the coding frame and dual coding of transcripts maximised rigour.

RESULTS

Twenty-eight GPs (10 fully qualified, 18 trainees) participated in five focus groups. Four major themes emerged: (1) why education is needed, (2) perceived educational needs, (3) learning preferences, and (4) evaluation preferences. EoLC was perceived as emotionally and clinically challenging. Educational needs included: identifying patients for palliative care; responsibilities and teamwork; out-of-hours care; having difficult conversations; symptom management; non-malignant conditions; and paediatric palliative care. Participants preferred learning through experience, working alongside specialist palliative care staff, and discussion of real cases, to didactic methods and e-learning. 360° appraisals and behavioural assessment using videoing or simulated interactions were considered problematic. Self-assessment questionnaires and patient and family outcome measures were acceptable, if used and interpreted correctly.

CONCLUSIONS

GPs require education and support in EoLC, particularly the management of complex clinical care and counselling. GPs value mentoring, peer-support, and experiential learning alongside EoLC specialists over formal training.

Place of care: from referral to specialist palliative care until death

BACKGROUND

While there are many poorly standardised studies focusing on place of death, there are limited data on place(s) of care during the final stages of disease.

AIM

This study aims to identify where patients are cared for in the interval from referral to specialist palliative care until death.

METHODS

All patients who died while under the care of a specialist palliative care service over a 6-month period were considered.

RESULTS

Of the 507 patients included, 255 (50.3%) were men and 428 (84.4%) had a malignant diagnosis. The mean referral-to-death interval was 70 days (SD 113, Range 1-838). The majority (n=281, 55.4%) received care in a single care setting-hospital (28.4%), home (21.5%), nursing home/community hospital (4.1%), hospice (1.4%)-and had a shorter mean referral-to-death interval. Most patients with more than one care setting spent three-quarters of their time in their normal place of residence. A total of 199 (39.3%) died in hospital, 131 (25.8%) in hospice, 131 (25.8%) at home (25.8%) and 46 (9.1%) in a nursing home/community hospital. Patients referred by a general practitioner (n=80 patients, 15.8%) were more likely to be cared for at home (p<0.001), and die at home (p<0.001).

CONCLUSIONS

A significant number of patients received specialist palliative care across multiple care settings. Late referral is associated with a single domain of care. General practitioner involvement supports patient care and death at home. Place of care and ease of transfer between care settings may be better indicators of the quality of care we provide.

The challenges of uncertainty and interprofessional collaboration in palliative care for non-cancer patients in the community: a systematic review of views from patients, carers and health-care professionals

BACKGROUND

Primary care has the potential to play significant roles in providing effective palliative care for non-cancer patients.

AIM

To identify, critically appraise and synthesise the existing evidence on views on the provision of palliative care for non-cancer patients by primary care providers and reveal any gaps in the evidence.

DESIGN

Standard systematic review and narrative synthesis.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, Applied Social Science Abstract and the Cochrane library were searched in 2012. Reference searching, hand searching, expert consultations and grey literature searches complemented these. Papers with the views of patients/carers or professionals on primary palliative care provision to non-cancer patients in the community were included. The amended Hawker's criteria were used for quality assessment of included studies.

RESULTS

A total of 30 studies were included and represent the views of 719 patients, 605 carers and over 400 professionals. In all, 27 studies are from the United Kingdom. Patients and carers expect primary care physicians to provide compassionate care, have appropriate knowledge and play central roles in providing care. The roles of professionals are unclear to patients, carers and professionals themselves. Uncertainty of illness trajectory and lack of collaboration between health-care professionals were identified as barriers to effective care.

CONCLUSIONS

Effective interprofessional work to deal with uncertainty and maintain coordinated care is needed for better palliative care provision to non-cancer patients in the community. Research into and development of a best model for effective interdisciplinary work are needed.

Disclosing the truth: a dilemma between instilling hope and respecting patient autonomy in everyday clinical practice

BACKGROUND

While medical ethics place a high value on providing truthful information to patients, disclosure practices are far from being the norm in many countries. Transmitting bad news still remains a big problem that health care professionals face in their every day clinical practice.

AIMS

Through the review of relevant literature, an attempt to examine the trends in this issue worldwide will be made.

METHOD

Various electronic databases were searched by the authors and through systematic selection 51 scientific articles were identified that this literature review is based on.

RESULTS

There are many parameters that lead to the concealment of truth. Factors related to doctors, patients and their close environment, still maintain a strong resistance against disclosure of diagnosis and prognosis in terminally ill patients, while cultural influences lead to different approaches in various countries. Withholding the truth is mainly based in the fear of causing despair to patients. However, fostering a spurious hope, hides the danger of its' total loss, while it can disturb patient-doctor relationship.

Psychiatric comorbidity among terminally ill patients in general practice in the Netherlands: a comparison between patients with cancer and heart failure

BACKGROUND

It is unclear whether psychiatric disorders are specifically related to the terminal phase of cancer, or independent of the underlying disease.

AIM

To investigate the rate of psychiatric comorbidity and psychotropic drugs prescription in terminally ill patients in the GP setting, comparing both patients with terminal cancer and heart failure.

DESIGN AND SETTING

Retrospective cohort study using the Utrecht General Practitioner Research Network.

METHOD

Equally-sized groups of patients with terminal cancer and heart failure were randomly selected from the database of four general practices over the years 2005-2009. Psychiatric comorbidities were determined using the International Classification for Primary Care (ICPC) codes and psychotropic drugs prescriptions using the Anatomical Therapeutic Chemical (ATC) Classification System codes.

RESULTS

A total of 191 terminally ill patients were included in the study (111 with cancer and 80 with heart failure). The mean age for patients with terminal cancer (70.8 years, standard deviation [SD] = 12.8) was 15 years younger than that of patients with heart failure (85.6 years, SD = 9.2). Half of the terminally ill patients (50.3 %) were prescribed psychotropics, but only 13.6% of them had obtained a psychiatric diagnosis. There were no significant differences in prevalence of psychiatric disease and psychotropic drug prescription between patients with terminal cancer and heart failure.

CONCLUSION

The results demonstrate a high use of psychotropic drugs in terminally ill patients, often in the absence of a formal diagnosis of a psychiatric disorder. The absence of differences between patients with cancer and heart failure suggests that psychiatric diagnoses and increased psychotropic prescriptions are primarily related to the terminal stage of the disease and not to the background of cancer or heart failure.

Attitudes of health care professionals to opioid prescribing in end-of-life care: a qualitative focus group study

CONTEXT

Opioid therapy is central to the management of pain in the field of generalist palliative and end-of-life care, and international guidelines highlight the need for opioids to be used as part of a comprehensive strategy to treat pain. However, evidence suggests that the use of opioids in palliative care is suboptimal, and many patients do not receive adequate pain control at the end of life.

OBJECTIVES

This study aimed to explore the attitudes of health care professionals to opioid prescribing in generalist end-of-life care.

METHODS

Thirty-one health and allied health professionals participated in four focus groups. Two focus groups took place in general practitioner practices and two in hospices.

RESULTS

Findings revealed that significant barriers exist to the appropriate use of opioids in end-of-life care. Particular barriers exist for professionals working in primary care and include concerns about giving high doses and having insufficient training in opioid use. Working partnerships between specialist and generalist palliative care providers are important for increasing generalist confidence in prescribing. Patients and their families often have concerns about initiating opioids, and specialist nursing staff are crucial to managing and alleviating these concerns.

CONCLUSION

Significant barriers exist to the appropriate use of opioids in end-of-life care. If international priorities on improving pain management at the end of life are to be achieved, educational opportunities for generalists need to be enhanced, and effective interprofessional working models need to be developed so that pain management for patients at the end of life is optimized.

The ACA training programme to improve communication between general practitioners and their palliative care patients: development and applicability

We describe the development of a new training programme on GP-patient communication in palliative care, and the applicability to GPs and GP Trainees. This ‘ACA training programme’ focuses on  A vailability of the GP for the patient,  C urrent issues that should be raised by the GP, and  A nticipating various scenarios. Evaluation results indicate the ACA training programme to be applicable to GPs and GP Trainees. The ACA checklist was appreciated by GPs as useful both in practice and as a learning tool, whereas GP Trainees mainly appreciated the list for use in practice.

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

BACKGROUND

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers.

AIM

To explore factors that support partnership working between specialist and generalist palliative care providers.

DESIGN

Systematic review.

METHOD

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

RESULTS

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

CONCLUSION

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.

'I deal with the small things': the doctor-patient relationship and professional identity in GPs' stories of cancer care

An important part of GPs' work consists of attending to the everyday and existential conditions of human being. In these life world aspects, biomedicine is often not the relevant theory to guide the GP; nevertheless they are a part of GPs' professional domain. In cancer care, previous studies have shown that GPs with a biomedical perspective on medicine could feel subordinate to specialists, and that doctors with a curative focus could see disease progression as a personal failure. The aim of this study was to explore in depth the experiences of being a GP for people with advanced cancer. Fourteen Norwegian GPs were interviewed about accompanying patients through a cancer illness. Their stories were analysed using a narrative approach. The GPs expressed a strong commitment to these patients, a loyalty which in some cases could be weakened due to judgements of distant specialists. In view of the GPs' close knowledge of their patients' background and history this subordination was a paradox, mirroring a hierarchy of medical knowledge. The GPs had an ideal of honesty and openness about death, which they sometimes failed. To reach the ideal of honesty, clinicians would have to abandon the biomedical ideal of mastering human nature through interventions and acknowledge the fundamental uncertainty and finiteness of human life. GPs may learn from being with their patients that bodily and existential suffering are connected, and thus learn implicitly to overlook the body-mind dualism. This practical wisdom lacks a theoretical anchoring, which is a problem not only for general practice.

On the journey with the dying: how general practitioners experience the death of their patients

A grounded theory study was undertaken to understand how general practitioners (GPs) experience the death of their patients. Eleven GPs participated in semistructured interviews. The participants explained their experience of a patient's death using the "death journey" metaphor. This journey, the Journey with the Dying, could be described from 5 different moments in the participants' encounters with people who are dying: private acknowledgement, communication of prognosis, continuity of care, the moment of death, and looking after the family. Emotional responses for each of the stages, and coping strategies in general, were outlined. GPs' narratives about professional identity, learning about dying and death, and death beliefs were also important in the Journey with the Dying. The experience of death described by the GPs in this study was different from that reported by medical doctors in other care settings. The 5 phases of the Journey with the Dying identified here show the different adjustments and appraisals that GPs undertake to comprehend and to be able to work in the presence of death.

[Specialized outpatient palliative care. The expectations of general practitioners]

BACKGROUND

The aim was to explore the expectations of general practitioners (GPs) towards specialized outpatient palliative care (SAPV) focused on older patients in the last phase of life.

METHODS

A standardized postal survey was carried out with 1,962 GPs in Lower Saxony with an analysis of physician and practice-related factors.

RESULTS

The response rate was 46% (n=897) and SAPV was known to 68% of the participants (n=599) of whom 48% (n=288) assumed that SAPV will improve the healthcare for older patients in the last phase of life. The GPs favored advice by and collaborative patient care with SAPV teams. Younger and female GPs, and GPs who had been practicing for a shorter period or working in a group practice showed greater interest in collaboration than other colleagues.

CONCLUSIONS

The perception of patients in specialized palliative care with its current focus on cancer patients is different from the perception in general practice with its focus on geriatric and multimorbid patients. This may be a reason for the skepticism showed in this study whether SAPV will actually improve healthcare in the community. However, with respect to the concept and framework SAPV has the potential to fulfill GPs expectations and should be focused on counseling and collaborative services. The knowledge about physician and practice-related factors shaping GPs attitudes towards SAPV can be helpful to further implement SAPV into practice.

Heartsink encounters: a qualitative study of end-of-life care in out-of-hours general practice

Objectives

We aimed to establish how prepared GPs who work regular out-of-hours shifts feel when dealing with end-of-life issues in palliative care patients, what they thought about seeing such patients and whether they considered themselves emotionally equipped to do so.

Design

Semi-structured interviews were conducted with GPs who worked regular out-of-hours shifts. A detailed analysis of transcripts using Interpretative Phenomenological Analysis was undertaken.

Setting

South Wales.

Participants

GPs employed by the local health board's out-of-hours service were contacted.

Main outcome measures

All interview data were analysed systematically and statements that reflected emotional impact and strain were highlighted, coded and interpreted within their context.

Results

GPs expressed unease and used terms such as ‘heartsink’, when having to deal with palliative care issues out-of-hours. Heartsink in this context referred to the subjective experience of the clinician. Emotional ‘housekeeping’, i.e. looking after oneself after emotionally-charged encounters, was felt to be a very important process and GPs used a range of coping mechanisms, including reflective time, sharing with peers, compartmentalisation and personal empathy to deal with stress.

Conclusion

The emotional effects of palliative care encounters on out-of-hours GPs should not be underestimated. Our interpretation distinguished the term ‘heartsink’ from its usual context, the ‘heartsink patient’, to a different meaning, that of the imminent palliative care encounter triggering a sensation of heartsink for some out-of-hours doctors. Therefore, the term ‘heartsink encounter’, rather than heartsink patient, seemed more fitting. Pressed services may encourage a culture where discussion or debrief with a colleague after a palliative care encounter is not perceived as a practical option. This may contribute to work-related burnout in this group of doctors and out-of-hours collaboratives need to be aware of this issue, when planning their services.

Perceived barriers and facilitators for general practitioner-patient communication in palliative care: a systematic review

While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP-patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs' lack of availability, and patients' and GPs' ambivalence to discuss 'bad prognosis'. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.

Who is the key worker in palliative home care?

OBJECTIVE

Palliative home care involves coordination of care between the professionals involved. The NICE guideline on supportive and palliative care (UK) recommends that teams, regardless of their base, should promote continuity for patients. This may involve nomination of a coordinating "key worker". This study aimed to explore who acts as key worker and who ought to take on this role in the views of patients, relatives, and primary care professionals. Furthermore, it aimed to explore the level of agreement on this issue between study participants.

DESIGN

Interview and questionnaire study.

SETTING

Former County of Aarhus, Denmark (2008-2009).

SUBJECTS

Ninety-six terminally ill cancer patients, their relatives, general practitioners (GPs), and community nurses (CNs).

MAIN OUTCOME MEASURES

Actual key worker as valued by patients, relatives, and primary care professionals; ideal key worker as valued by patients and relatives. RESULTS. Patients, relatives, GPs, and CNs most often saw themselves as having been the key worker. When asked about the ideal key worker, most patients (29%; 95%CI: 18;42) and relatives (32%; 95%CI: 22;45) pointed to the GP. Using patients' views as reference, we found very limited agreement with relatives (47.7%; k = 0.05), with GPs (30.4%; k = 0.01) and with CNs (25.0%; k = 0.04). Agreement between patients and relatives on the identity of the ideal key worker was of a similar dimension (29.6%; k = 0.11).

CONCLUSION

Poor agreement between patients, relatives, and professionals on actual and ideal key worker emphasizes the need for matching expectations and clear communication about task distribution in palliative home care.

Facilitators and barriers for GP-patient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants

BACKGROUND

Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care.

AIM

To obtain detailed information on facilitators and barriers for GP-patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills.

DESIGN OF STUDY

Qualitative study with focus groups, interviews, and questionnaires.

SETTING

GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands.

METHOD

GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers.

RESULTS

Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors' delay and strong demands from patients' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor-patient relationships, while consultants report insufficient clarification of patients' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios.

CONCLUSION

The study findings suggest that the quality of GP-patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated.

Bereavement care in primary care: a systematic literature review and narrative synthesis

BACKGROUND

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

AIM

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them. design systematic literature review.

METHOD

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

RESULTS

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to 'medicalise' normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

CONCLUSION

A small number of studies were identified, most of which were > 10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.

Experiences and Attitudes of Patients With Terminal Cancer and Their Family Caregivers Toward the Disclosure of Terminal Illness

Purpose

We investigated the experiences of cancer patients and their family caregivers who became aware that the cancer was terminal, how they became aware, and how they felt about disclosure of the information.

Patients and Methods

In this cohort study, we administered questionnaires to 619 consecutive patients determined by physicians to be terminally ill and to their family caregivers.

Results

A total of 481 patients and 381 family caregivers completed the questionnaire. A majority of patients (58.0%) and caregivers (83.4%) were aware of the patient's terminal status. Approximately 28% of patients and 23% of caregivers reported that they guessed it from the patient's worsening condition. The patient group was more likely than the caregiver group (78.6% v 69.6%) to prefer that patients be informed of their terminal status. Patients informed of their terminal diagnosis had a significantly better quality of life and fewer symptoms and had a lower rate of emotional distress than patients who guessed it from their worsening condition. Younger patients and patients who paid the treatment costs themselves were significantly more likely to want to be told when their illness was terminal. If the patient paid the treatment cost and was employed at the time of the cancer diagnosis, the family caregivers were more likely to prefer disclosure of terminal illness.

Conclusion

Most patients with terminal cancer and their family caregivers preferred disclosure, and patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life.

Retrospective evaluation of palliative care in Romania: the perspective of the involved professionals

OBJECTIVE

Palliative care at home is a new service provision in Romania. This study evaluated retrospectively, after the patient's death, the provision of care at home from the perspective of professionals directly involved in the care process. The evaluation included assessment of the role of the professional, the functioning of the team, communication with patients and family, and overall judgment. The study is part of the development of palliative care at home, by multidisciplinary teams in Romania.

METHODS

Over a period of eighteen months five teams with a total of 19 professionals, provided palliative care for 103 patients with cancer in its terminal stage. During this period 80 patients died. A questionnaire was sent to the professionals involved. All responded resulting in 181 evaluations. These evaluations are the basis for analysis. The data were analyzed using SPSS.

RESULTS

Of the 181 cases evaluated, 63 indicated an emotional burden on the professionals. GP's and nurses reported such a burden more frequently. A lack of knowledge of how to treat a special case was reported 56 times. This was especially so when a case was judged to be different from other cases, which often included (unexpected) complications. GP's reported cases with complications more frequently than oncologists and nurses. The multidisciplinary teams functioned very satisfactorily in treating patients. Although communication with patients/families was generally judged positively, communication with patients was sometimes viewed as problematic. The overall verdict was that the care delivered to the 80 patients was positive. Most professionals reported that they would deal with the cases in the same way again.

CONCLUSIONS

The patients who received palliative care and died, were treated well according to the professionals who evaluated the care process. Improvement of palliative care services at home may be achieved by provision of additional information on (acute) complications. Since palliative care at home is a new phenomenon in Romania, professionals working closely with the patient have to learn to cope with the emotional burden certain cases may include.

An Insight Into the Delivery of a Palliative Approach in Residential Aged Care

Managing the complex care needs of older people is a global concern. General practitioners (GPs) play a pivotal role in aged care, yet little is known about their capacity to provide palliative care in nursing homes. This study aimed to investigate GPs' perceptions and understanding of a palliative approach. A convenience sample of rural GPs ( n = 13) participated in a series of three focus groups undertaken in August, 2005. These focus groups were all audio-taped, transcribed, and analyzed using thematic content analysis. Four key themes emerged: uncertainty about a palliative approach, a need to reorientate providers, the challenges of managing third parties, and making it work and moving forward. These preliminary findings suggest that integrating a palliative approach in aged care requires GPs to have a greater awareness of this paradigm and to be more effectively engaged in multidisciplinary care planning.

General practitioners' use and experiences of palliative care services: a survey in south east England

Background

The role of the General Practitioner (GP) is central to community palliative care. Good liaison between the different professionals involved in a patient's care is extremely important in palliative care patients. In cases where GPs have previously been dissatisfied with palliative services, this may be seen as a barrier to referral when caring for other patients. The aim of this survey is to investigate the use and previous experiences of GPs of two palliative care services, with particular emphasis on barriers to referral and to explore issues surrounding the GP's role in caring for palliative patients.

Methods

Design: Descriptive postal survey of use and experience of palliative care services with particular emphasis on barriers to referral. Setting: One Primary Care Trust (PCT), south London, England, population 298,500. Subjects: 180 GPs in the PCT, which is served by two hospice services (A&B).

Results

An overall questionnaire response rate of 77% (138) was obtained, with 69% (124) used in analysis. Over 90% of GPs were satisfied with the palliative care services over the preceding two years. Two areas of possible improvement emerged; communication and prescribing practices. GPs identified some patients that they had not referred, most commonly when patients or carers were reluctant to accept help, or when other support was deemed sufficient. Over half of the GPs felt there were areas where improvement could be made; with clarification of the rules and responsibilities of the multi disciplinary team being the most common. The majority of GPs were working, and want to work with, the specialist services as part of an extended team. However, a greater number of GPs want to hand over care to the specialist services than are currently doing so.

Conclusion

A large number of GPs were happy with the service provision of the palliative care services in this area. They suggested that 3 out of 4 terminally ill patients needed specialist input. Views of services were largely positive, and reasons for non referral were unrelated to previous experience of the specialist services.

Facing uncertainty: the lived experience of palliative care

OBJECTIVE

This qualitative research study listens to the narratives of people experiencing the dying process who attended the Otago Community Hospice, Dunedin, New Zealand.

METHODS

Ten people, aged between 51 and 65, were approached; two declined and one died sooner than expected. All were women (although this was not part of the original design) and all had carcinoma. Data for the study was sought through qualitative research interviews, considering the development of each participant's illness in relation to her perception of her embodiment in the palliative care setting, and concluding with questions about what she wants the people who care for and about her to learn from her experience. Consistent with this phenomenological approach, the method of analysis was thematic and interpretive.

RESULTS

The main theme was the uncertainty that all participants felt throughout the diagnostic process and during treatment. Uncertainty, too, was a factor in how they managed their day, whether they would be able to sustain an outing or an activity or not and whether they would be pain free. None were afraid of dying but hoped that when they did die, they would do so comfortably. The relationship with their general practitioners varied. Where fatigue or the effects of medication were not an issue, they could think clearly, but their bodies were experienced as letting them down and limiting their activities. The ideal of "living until you die" was not able to be fulfilled. The increasing approach of social death as they withdrew from their employment and social responsibilities affected them.

SIGNIFICANCE OF RESULTS

Whether one has a "good death" or not is determined not only by the progression and management of the disease process by health professionals, but also by the way in which one is perceived, by self and others. There are no guidelines for the dying role; everybody dies differently and individually.

Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in The Netherlands

OBJECTIVE

To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home.

DESIGN

In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers.

SETTING

Second Dutch National Survey in General Practice.

SUBJECTS

A total of 743 patients who received palliative care according to their GP.

MAIN OUTCOME MEASURES

Interdisciplinary cooperation between GP and other healthcare providers.

RESULTS

During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care.

CONCLUSION

In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.

Palliative Care Consultation, Quality-of-Life Measurements, and Bereavement for End-of-Life Care in Patients With Lung Cancer

OBJECTIVE

To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer.

METHODS

To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients.

RESULTS

Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death.

CONCLUSION

Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Assessing palliative care needs: views of patients, informal carers and healthcare professionals

AIM

This paper reports a study to assess the palliative care needs of the adult population served by a healthcare provider organization in Northern Ireland from the perspectives of patients, informal carers and healthcare providers.

BACKGROUND

Assessing palliative care need is a key factor for health service planning. Traditionally, palliative care has been associated with end-of-life care and cancer. More recently, the concept has been extended to include care for both cancer and non-cancer populations. Various approaches have been advocated for assessing need, including the exploration of professional provider and user perspectives of need.

METHOD

Semi-structured qualitative interviews were undertaken with a purposive sample of patients and lay carers receiving palliative care services (n = 24). Focus groups were also conducted with multi-professional palliative care providers (n = 52 participants) and face to face interviews were undertaken with key managerial stakeholders in the area (n = 7). The focus groups and interviews concentrated on assessment of palliative care need. All the interviews were transcribed verbatim and analysed using Burnard's framework.

FINDINGS

Professional providers experienced difficulty in defining the term palliative care. Difficulties in communication and information exchange, and fragmented co-ordination between services were identified. The main areas of need identified by all participants were social and psychological support; financial concerns; and the need for choice and information. All participants considered that there was inequity between palliative care service provision for patients with cancer and non-cancer diseases.

CONCLUSION

All patients, regardless of diagnosis, should be able to access palliative care appropriate to their individual needs. For this to happen in practice, an integrated approach to palliative care is essential. The study methodology confirms the value of developing a comprehensive approach to assessing palliative care need.

Concerns about Losing Control When Breaking Bad News to Terminally Ill Patients with Cancer: Physicians' Perspective

OBJECTIVE

To study and explore problems perceived by physicians when breaking bad news to advanced cancer patients about discontinuing or not offering tumor-specific treatment due to incurable cancer.

DESIGN

A qualitative phenomenographic interview study.

SETTING

The county of Ostergötland in Sweden.

PARTICIPANTS

Thirty physicians with different demographic characteristics.

RESULTS

According to the physicians' answers breaking bad news was perceived as involving a risk of losing control in different ways, regarding emotions, oneself, confidence, professionalism and patient trust. Four different main categories described as problems were identified; perceptions focusing on existential thoughts, relationships, knowledge, and perceptions related to time and environmental disturbances.

CONCLUSION

Physicians perceived that breaking bad news to dying patients with cancer involved a risk of losing control. Existential thoughts and a lack of knowledge contribute to this risk. Theoretical education in existentiality/spirituality and clinical practice in a palliative context may help maintaining control.

Barriers to effective communication across the primary/secondary interface: examples from the ovarian cancer patient journey (a qualitative study)

Effective communication across the primary/secondary interface is vital for the planning and delivery of appropriate patient care throughout the cancer patient journey. This study describes GPs' views of the communication issues across the primary/secondary interface in relation to ovarian cancer patients using qualitative interviews with purposively sampled general practitioners (GPs) and an audit of hospital medical records of 30 deceased ovarian cancer patients. Issues raised by the GPs related to the content and format of communications, but of most concern was the tardiness. The time lag between dictation and typing letters ranged from 0 to 27 days, with a delay of up to 8 days for signing before transit through various mail systems to the GP. Three stages in the patient journey were characterized by particular issues: (1) in the pre-diagnostic and diagnostic stage was a need for prompt information regarding the results of tests and diagnoses, and clearer guidance on the use of tests and fast-track referrals; (2) in the active treatment phase, when GPs could lose touch with their patients, they needed effective communication in order to provide moral support and crisis management; and (3) when oncology withdrew and the focus of care switched back to the community for the terminal phase, GPs needed information to enable them to pick up the baton of care. There is a need to develop and evaluate interventions aimed at improving the content and speed of communications between secondary and primary care. Such interventions are likely to be complex and might include the greater use of telephone or fax for more selected communications, a review of secretarial support, the use of email, the development of GP designed proformas, the feasibility of patient/carer letter delivery options, nurse-led communication, universal electronic patient records, or a revisiting of the patient-held record.

Comparison of Medical Treatments for the Dying in a Hospice and a Geriatric Hospital in Japan

CONTEXT

Most older adults who die in Japan do so in the hospital without receiving hospice or palliative care. While there are some hospices in Japan, little is known about the care they provide to the elderly.

OBJECTIVE

To clarify how the care of dying patients differs in a hospice and a geriatric hospital in Japan.

DESIGN

Cohort study.

SETTING

A hospice and a geriatric hospital in Japan.

PARTICIPANTS

One hundred ninety-one inpatients aged 65 or older.

MAIN OUTCOME

Areas of our interest: (1) gender and age; (2) primary disease(s) and cause of death; (3) observed symptoms/conditions and medical treatment or care conducted within 48 hours prior to death; (4) the actual topics leading to disclosure; and (5) whether or not advance directives had been given.

RESULTS

The X2 test determined that there were statistically significant differences between a geriatric hospital and a hospice, with respect to mean age, diagnoses on admission, primary cause of death, symptoms/conditions, and the practice of medical interventions. However, controlling for patient characteristics and assuming a bivariate distribution between the probabilities of choosing a facility and of undergoing a medical procedure, we found that patients at the hospice were more likely to undergo treatment with opioids, urethral catheter, and oral medicine; such patients were less likely to undergo oxygen inhalation, total parenteral nutrition, and other intravenous drips.

CONCLUSION

The hospice examined in this study was similar to the approach regarding medical treatments observed at the geriatric hospital.

Learning to Cope: How Far Is Too Close?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital, founded The Kenneth B. Schwartz Center. The Schwartz Center is a nonprofit organization dedicated to advancing compassionate health care delivery, with the goal of providing hope to patients and support to caregivers. The Schwartz Center Rounds is a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, families, and caregivers, and gain insight and support from fellow staff members. The case is presented of a patient with a precipitous decline in health due to rapidly progressive, metastatic non-small cell lung cancer. The discussion at Schwartz Center Rounds centers on oncologists' feelings of failure and coping mechanisms when dealing with patients' deaths. This discussion is followed by a first-year oncology fellow's reaction to caring for this and other terminally ill patients. Then, to provide a broader framework in which to understand these issues, the emotional cost and measurable benefit of close relationships with patients is investigated. To conclude, further educational initiatives are advocated to assist both physicians-in-training and more senior clinicians in dealing with the difficult issues that arise when caring for very ill and dying patients.

Palliative care for patients with cancer: district nurses' experiences

AIM

This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families.

BACKGROUND

There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care.

METHOD

A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis.

FINDINGS

Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring.

CONCLUSIONS

District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.

Cooperating with a palliative home-care team: expectations and evaluations of GPs and district nurses

BACKGROUND

Palliative home-care teams often cooperate with general practitioners (GPs) and district nurses. Our aim was to evaluate a palliative home-care team from the viewpoint of GPs and district nurses.

METHODS

GPs and district nurses received questionnaires at the start of home-care and one month later. Questions focussed on benefits to patients, training issues for professionals and cooperation between the home-care team and the GP/ district nurse. A combination of closed- and open-ended questions was used.

RESULTS

Response rate was 84% (467/553). Benefits to patients were experienced by 91 %, mainly due to improvement in symptom management, 'security', and accessibility of specialists in palliative care. After one month, 57% of the participants reported to have learnt aspects of palliative care, primarily symptom control, and 89% of them found cooperation satisfactory. Dissatisfaction was caused mainly by lack of information from the home-care team to primary-care professionals.

CONCLUSION

GPs and district nurses welcomed the palliative home-care team and most experienced benefits to patients. Strengthened communication, initiated by the home-care team would enhance cooperation.

General practitioners (GPs) and palliative care: perceived tasks and barriers in daily practice

BACKGROUND

General practitioners (GPs) play a crucial part in palliative care. The quality of care can be improved by investigating and addressing barriers perceived by GPs in daily practice. The aim of this study was to investigate GPs' task perception and barriers involved in palliative care.

METHODS

Qualitative focus group study. We gathered together a group of GPs representing a broad range of experience in palliative care. Content analysis was performed to derive a comprehensive view of tasks and barriers in daily palliative care.

RESULTS

GPs described their palliative care tasks as satisfactory and varied, but burdensome. Palliative care tasks included somatic and psychosocial care. Opinions differed with respect to whether the coordination of care belonged to the primary GP tasks. Barriers were classified according to three levels: (1) personal: barriers related to knowledge, skills, emotions; (2) relational: barriers concerning communication and collaboration; (3) organizational: barriers related to the organization of care and compartmentalization in healthcare.

CONCLUSIONS

This study revealed a complex web of tasks and barriers. It may be possible to trace back a problem (lack of knowledge, for example) on the personal level to an isolated knowledge gap, but the problem may well have originated from communication or compartmentalization problems. To maintain GPs' feeling of being at ease with palliative care requires helping them acquire the appropriate balance between technical and organizational interventions and a compassionate orientation to their terminally ill patients.

Palliative care in the community for cancer and end-stage cardiorespiratory disease: the views of patients, lay-carers and health care professionals

Primary care plays an important role in delivering care to people who are dying. However, providing palliative care to people dying with conditions other than cancer may be more problematic, because it may be more difficult to establish an exact prognosis or to identify their needs. This article draws on qualitative research, which explored the views of health professionals, patients and their carers about care provided at the end of life. Differences between the care of people with cancer and those with end-stage cardiorespiratory disease were found in four main areas: management and progression of disease, communication and information, health care in the community and awareness of dying. The research shows that even in PHCTs (primary health care teams) committed to the delivery of palliative care, people dying with end-stage cardiorespiratory disease are less likely than those with cancer to receive full, and easily understood, information, to be aware that they are dying or to receive district nursing care. There is an increasing call for palliative care to be extended to all, but further work is needed to develop appropriate packages of care for those dying with conditions other than cancer.

Community hospitals: an under-recognized resource for palliative care

In the UK there are concerns that, in certain groups of dying patients such as the old, those with non-cancer diagnoses and those in rural areas, the quality of care is unacceptably variable. There has been no systematic survey of the extent to which community hospitals provide general palliative care for such patients. Therefore, by means of a structured questionnaire we asked senior nurses/managers at all 478 community hospitals in the UK for information on staff expertise, facilities and specialist equipment, liaison arrangements with specialist palliative care providers, priorities, practice and policy in end-of-life care. Of the 346 hospitals (72%) that responded, only 28 were in urban areas. 73% of hospitals employed at least one nurse with additional training in palliative care, 72% had access to 24-hour specialist palliative care advice and 51% had separate overnight accommodation for relatives, but only 22% had designated palliative care beds. Most hospitals did not have written policies or guidelines for patient assessment or symptom control. These findings add to evidence that community hospitals represent an important resource to improve access to palliative care for groups that are currently under-served.