Palliative Care Provision by Rural General Practitioners in New Zealand

Palliative care for rural growth and wellbeing: identifying perceived barriers and facilitators in access to palliative care in rural Indiana, USA

With the growing aging population and high prevalence of chronic illnesses, there is an increasing demand for palliative care. In the US state of Indiana, an estimated 6.3 million people are living with one or more chronic illnesses, a large proportion of them reside in rural areas where there is limited access to palliative care leading to major healthcare inequities and disparities. This study aims to identify common barriers and facilitators to access palliative care services in rural areas of Indiana from the perspectives of healthcare providers including clinicians, educators, and community stakeholders. Using a community-based participatory approach, a purposive sample of palliative care  providers (n = 15) in rural areas of Indiana was obtained. Penchansky and Thomas (1981) theoretical framework of access was used to guide the study. A semi-structured individual in-depth interview guide was used to collect the data. All the interviews were conducted online, audio-recorded, and transcribed. Barriers to palliative care  include: misconceptions about palliative care as an underrecognized specialty; lack of trained palliative care providers; late involvement of inpatient palliative care and community hospice services; inadequate palliative care education and training; financial barriers, attitudes and beliefs around PC; and geographical barriers. Facilitators to palliative care include financial gains supporting palliative care growth, enhanced nurses’ role in identifying patients with palliative care needs and creating awareness and informing the community about palliative care. Robust education and awareness, enhancing advanced practice nurses’ roles, increasing funding and resources are essential to improve the access of palliative care services in the rural communities of Indiana.

Examining Barriers and Facilitators to Palliative Care Access in Rural Areas: A Scoping Review

BACKGROUND

Despite the growth of palliative care (PC), access to PC remains challenging for rural Americans living with chronic diseases. Given the demand and benefits of PC, a comprehensive view of PC access would inform policymakers in developing PC services in rural areas.

OBJECTIVE

This scoping review aimed to understand the barriers and facilitators to PC access in rural areas from the voices of service users and service providers during the past decade.

METHODS

A scoping literature review was conducted from 2010 to 2020 using MEDLINE, CINAHL, and PsychINFO databases. Results: Twenty-eight studies met inclusion criteria. Barriers to PC access in rural areas mostly arose in structural issues: (1) the inadequate knowledge and awareness of PC among both service users and providers and (2) the poorly structured PC system. Other barriers included communication gaps/challenges between providers and patients/families and cultural barriers. The facilitators mainly originated in patients/families' connectedness with local providers and with other social networks such as friends.

CONCLUSIONS

These findings highlight the need for funding support to increase provider competency, service availability and accessibility, and the public knowledge and awareness of PC in rural areas. A holistic and tailored PC model that standardizes care delivery, referral and coordination, including family caregiver support programs, can improve care access. Future practice and research are warranted to implement and evaluate innovative approaches, such as a coordinated community-based approach, to the successful integration of PC in rural communities.

Preplanned participation of paramedics in end-of-life care at home: A retrospective cohort study

BACKGROUND

Paramedics commonly face acute crises of patients in palliative care, but their involvement in end-of-life care is not planned systematically.

AIM

To evaluate a protocol for end-of-life care at home including pre-planned integration of paramedics and end-of-life care wards.

DESIGN

Paramedic visits to patients in end-of-life care protocol were retrospectively studied.

SETTING/PARTICIPANTS

All of the patients who had registered for the protocol between 1 March 2015 and 28 February 2017 in North Karelia, Finland, were included in this study.

RESULTS

A total of 256 patients were registered for the protocol and 306 visits by paramedic were needed. A need for symptom control (38%) and transportation (29%) were the most common reasons for a visit. Paramedics visited 43% and 70% of the patients in areas with and without 24/7 palliative home care services, respectively (p < 0.001); while 58% of all the visits were done outside of office hours. Problems were resolved at home in 31% of the visits. The patient was transferred to a pre-planned end-of-life care ward and to an emergency department in 48% and 16% of the cases, respectively. More patients died in end-of-life care wards in areas without (54%) than with (33%) 24/7 home care services (p = 0.001).

CONCLUSIONS

Integration of paramedics into end-of-life care at home is reasonable especially in rural areas without 24/7 palliative care services and outside of office hours. The majority of patients can be managed at home or with the help of an end-of-life care ward without an emergency visit.

Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review

BACKGROUND

General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood.

OBJECTIVE

To provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC.

METHOD

Systematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 62 reviewed papers reported the GP's and GPN's role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC.

CONCLUSIONS

While primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.

Timing of Palliative Care in Colorectal Cancer Patients: Does It Matter?

BACKGROUND

Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs.

METHODS

This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs.

RESULTS

A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care.

CONCLUSIONS

Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.

Engagement of Primary Care Physicians in Home Palliative Care

PURPOSE

To describe prevalence and characteristics associated with family physician and general practitioner (FP/GP) provision of home palliative care (HPC).

METHODS

We surveyed FP/GPs in an urban health region of Ontario, Canada, to determine their current involvement in HPC, the nature of services provided, and perceived barriers and enablers.

RESULTS

A total of 1439 surveys were mailed. Of the 302 FP/GP respondents, 295 provided replies regarding engagement in HPC: 101 of 295 (33%) provided HPC, 76 (26%) were engageable with further support, and 118 (40%) were not engageable regardless of support. The most substantial barrier was time to provide home visits (81%). Engaged FP/GPs were most likely to be working with another physician providing HPC ( P < .0001). Engageable FP/GPs were younger ( P = .007) and placed greater value on improved remuneration ( P < .001) than the other groups. Nonengageable physicians were most likely to view time as a barrier ( P < .0001) and to lack interest in PC ( P = .03).

CONCLUSION

One-third of FP/GPs provide HPC. A cohort of younger physicians could be engageable with adequate support. Integrated practices including collaboration with specialist PC colleagues should be encouraged and supported.

The Role of Primary Care Physicians in Providing End-of-Life Care

BACKGROUND

Primary care physicians (PCPs) frequently have long-term relationships with patients as well as their families. As such they are well positioned to care for their patients at the end of their lives. As the number of patients in need of end-of-life care continues to grow, it is critical to understand how PCPs can fulfill that need. The purpose of our study is to perform a narrative review of the literature and develop a theoretical model delineating the overarching roles played by PCPs in caring for patients at the end of life.

METHODS

For this narrative review, the authors searched Medline (PubMed), Embase, Cochrane Library, and Scopus up to March 22, 2017. Articles were not limited by geography.

RESULTS

Review of existing literature generally supports 4 broad categories as the primary roles for PCP involvement in end of life: pain and symptom management; information management, including transmitting and clarifying information, setting care priorities, and assisting patients with treatment decisions; coordinating care and collaborating with other providers; and addressing patients' social, emotional, and spiritual needs.

CONCLUSIONS

Based on the results of this review, PCPs provide a wide range of services to patients at the end of life. Promoting the provision of the full scope of services by PCPs will help ensure improved continuity of care while providing the highest quality of care for patients, both in the United States and around the world.

How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review

BACKGROUND

The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported.

AIM

(i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context.

DESIGN

A systematic review.

DATA SOURCES

Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective.

RESULTS

A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified.

CONCLUSIONS

The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.

Place of death in the Snowy Monaro region of New South Wales: A study of residents who died of a condition amenable to palliative care

OBJECTIVE

To describe the place of death of residents in a rural region of New South Wales.

DESIGN

Cross-sectional quantitative study using death data collected from local funeral directors (in person and websites), residential aged-care facilities, one multipurpose heath service and obituary notices in the local media (newspapers/radio).

SETTING

Snowy Monaro region (New South Wales Australia).

PARTICIPANTS

Residents, with advanced frailty or one of 10 conditions amenable to palliative care, who died between 1 February 2015 and 31 May 2016.

MAIN OUTCOME MEASURE

Place of death.

RESULTS

Of 224 deaths in this period, 138 were considered amenable to palliative care. Twelve per cent of these deaths occurred in a private residence, 38% in the usual place of residence and 91% within the region.

CONCLUSION

Most rural residents with conditions amenable to palliative care died in the region. Most did not die in their usual place of residence. Further qualitative work is needed to determine palliative care patients' and family caregivers' preferences for, and the importance placed on, place of death. While there may be a need to support an increase in home deaths, local rural hospitals and residential aged-care facilities must not be overlooked as a substitute for inpatient hospices.

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand

With the future focus on palliative and end-of-life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co-ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants' understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of 'generalism' and 'specialism' also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care.

Place of death in rural palliative care: A systematic review

BACKGROUND

There have been many studies on the actual and preferred place of care and death of palliative patients; however, most have been whole population surveys and/or urban focused. Data and preferences for terminally ill rural patients and their unofficial carers have not been systematically described.

AIM

To describe the actual place of death and preferred place of care and/or death in rural palliative care settings.

METHOD

A systematic mixed studies review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

DATA SOURCE

PubMed, PsychINFO, Scopus and CINAHL databases were searched (September to December 2014); eligible quantitative and qualitative studies included preferred and/or actual place of death/care of rural, regional or remote residents; rural data that are clearly identifiable; death due to palliative condition (malignant and non-malignant) or survey of participants with current or hypothetical life-limiting illness.

RESULTS

A total of 25 studies described actual place of death; 12 preferred place of care or death (2 studies reported both); most deaths occurred in hospital with home as the preferred place of care/death; however qualitative studies suggest that preferences are not absolute; factors associated with place are not adequately described as rurality was an independent variable; significant heterogeneity (rural setting and participants), however, many areas had a greater chance of home death than in cities; rural data are embedded in population reports rather than from specific rural studies.

CONCLUSION

Home is the preferred place of rural death; however, more work is needed to explore influencing factors, absolute importance of preferences and experience of providing and receiving palliative care in rural hospitals which often function as substitute hospice.

Reducing avoidable admissions in rural community palliative care: a pilot study of care coordination by General Practice registrars

OBJECTIVE

To investigate the feasibility of using a General Practice registrar (GPR) to coordinate rural palliative care services.

DESIGN

A quasi-experimental design was used. Intervention group participants received the GPR service, which involved liaison among the patient, family, General Practitioner, specialist palliative care team and community nurses. Specified risk assessment, care planning and continuity of care were provided. Patients in the comparison group received the standard service.

SETTING

Rural community palliative care.

PARTICIPANTS

One hundred and ninety-one rural community palliative care patients (99 intervention and 92 control patients).

MAIN OUTCOME MEASURES

Hospital admissions per 100 patient-days, bed-days per 100 patient-days and proportion of deaths at home.

RESULTS

Patients receiving standard care were twice as likely to spend ≥8 bed-days in hospital (OR 2.09 (95%CI 1.10-3.97); P = 0.02) and were more likely to have ≥ 2 admissions to hospital (OR 3.37 (95%CI 1.83-6.21); P < 0.001), per 100 patient-days than the intervention group after adjusting for diagnosis group (cancer or not) and residence in residential aged care. Controls were significantly less likely to die at home than the intervention group (OR 0.41 (95%CI 0.20-0.86); P = 0.02).

CONCLUSION

This is a small proof of concept pilot study limited by lack of randomisation. The results demonstrate the feasibility of using a GPR to manage continuity of care for rural community palliative care patients. Given the potential confounding factors, further investigation via a larger randomised trial is required.

Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations

BACKGROUND

People living in rural and remote locations are disadvantaged in accessing palliative care. This can be attributed to several factors including the role diversity and the low numbers of patients with specific conditions, as well as the difficulties rural health practitioners have in accessing opportunities for professional education. A program of multidisciplinary palliative care video conferences was presented to health practitioners across part of northern Australia in an effort to address this problem.

METHOD

The educational content of the video conferences was developed from participant responses to an educational needs assessment. Following cycles of four consecutive video conferences, 101 participants completed evaluative on-line surveys. The quantitative data were analysed using frequencies and analysis of variance tests with post-hoc analyses where appropriate, and an accessibility and remoteness index was used to classify their practice location.

RESULTS

All participants found the content useful regardless of their remoteness from the tertiary centre, their years of experience caring for palliative care patients or the number of patients cared for each year. However, change in confidence to provide palliative care as a result of attending the video conferences was significant across all disciplines, regardless of location. Doctors, medical students and allied health professionals indicated the greatest change in confidence.

CONCLUSIONS

The provision of professional education about palliative care issues via multidisciplinary video conferencing increased confidence among rural health practitioners, by meeting their identified need for topic and context specific education. This technology also enhanced the networking opportunities between practitioners, providing an avenue of ongoing professional support necessary for maintaining the health workforce in rural and remote areas. However, more attention should be directed to the diverse educational needs of allied health professionals.

Among neighbors: an ethnographic account of responsibilities in rural palliative care

OBJECTIVE

Building high quality palliative care in rural areas must take into account the cultural dimensions of the rural context. The purpose of this qualitative study was to conduct an exploration of rural palliative care, with a particular focus on the responsibilities that support good palliative care from rural participants' perspectives.

METHOD

This ethnographic study was conducted in four rural communities in Western Canada between June 2009 and September 2010. Data included 51 days of field work, 95 semistructured interviews, and 74 hours of direct participant observation. Thematic analysis was used to provide a descriptive account of rural palliative care responsibilities.

RESULTS

Findings focus on the complex web of responsibilities involving family, healthcare professionals, and administrators. Family practices of responsibility included provision of direct care, managing and coordinating care, and advocacy. Healthcare professional practices of responsibility consisted of interpreting their own competency in relation to palliative care, negotiating their role in relation to that interpretation, and individualizing care through a bureaucratic system. Administrators had three primary responsibilities in relation to palliative care delivery in their community: navigating the politics of palliative care, understanding the culture of the community, and communicating with the community.

SIGNIFICANCE OF RESULTS

Findings provide important insights into the complex ways rurality influences understandings of responsibility in palliative care. Families, healthcare providers, and administrators work together in fluid ways to support high quality palliative care in their communities. However, the very fluidity of these responsibilities can also work against high quality care, and are easily disrupted by healthcare changes. Proposed healthcare policy and practice changes, particularly those that originate from outside of the community, should undergo a careful analysis of their potential impact on the longstanding negotiated responsibilities.