Palliative care in the hinterlands: a description of existing services and doctors' attitudes

New alumni EXperiences of Training and independent Unsupervised Practice (NEXT-UP): protocol for a cross-sectional study of early career general practitioners

INTRODUCTION

General practice in Australia, as in many countries, faces challenges in the areas of workforce capacity and workforce distribution. General practice vocational training in Australia not only addresses the training of competent independent general practitioners (GPs) but also addresses these workforce issues. This study aims to establish the prevalence and associations of early career (within 2 years of completion of vocational training) GPs' practice characteristics; and also to establish their perceptions of utility of their training in preparing them for independent practice.

METHODS AND ANALYSIS

This will be a cross-sectional questionnaire study. Participants will be former registrars ('alumni') of three regional training organisations (RTOs) who achieved general practice Fellowship (qualifying them for independent practice) between January 2016 and July 2018 inclusive. The questionnaire data will be linked to data collected as part of the participants' educational programme with the RTOs. Outcomes will include alumni rurality of practice; socioeconomic status of practice; retention within their RTO's geographic footprint; workload; provision of nursing home care, after-hours care and home visits; and involvement in general practice teaching and supervision. Associations of these outcomes will be established with logistic regression. The utility of RTO-provided training versus in-practice training in preparing the early career GP for unsupervised post-Ffellowship practice in particular aspects of practice will be assessed with χ² tests.

ETHICS AND DISSEMINATION

Ethics approval is by the University of Newcastle Human Research Ethics Committee, approval numbers H-2018-0333 and H-2009-0323. The findings of this study will be widely disseminated via conference presentations and publication in peer-reviewed journals, educational practice translational workshops and the GP Synergy Research subwebsite.

Community readiness and momentum: identifying and including community-driven variables in a mixed-method rural palliative care service siting model

BACKGROUND

Health service administrators make decisions regarding how to best use limited resources to have the most significant impact. Service siting models are tools that can help in this capacity. Here we build on our own mixed-method service siting model focused on identifying rural Canadian communities most in need of and ready for palliative care service enhancement through incorporating new community-driven insights.

METHODS

We conducted 40 semi-structured interviews with formal and informal palliative care providers from four purposefully selected rural communities across Canada. Communities were selected by running our siting model, which incorporated GIS methods, and then identifying locations suitable as qualitative case studies. Participants were identified using multiple recruitment methods. Interviews were transcribed verbatim and the transcripts were reviewed to identify emerging themes and were coded accordingly. Thematic analysis then ensued.

RESULTS

We previously introduced the inclusion of a 'community readiness' arm in the siting model. This arm is based on five community-driven indicators of palliative care service enhancement readiness and need. The findings from the current analysis underscore the importance of this arm of the model. However, the data also revealed the need to subjectively assess the presence or absence of community awareness and momentum indicators. The interviews point to factors such as educational tools, volunteers, and local acknowledgement of palliative care priorities as reflecting the presence of community awareness and factors such as new employment and volunteer positions, new care spaces, and new projects and programs as reflecting momentum. The diversity of factors found to illustrate these indicators between our pilot study and current national study demonstrate the need for those using our service siting model to look for contextually-relevant signs of their presence.

CONCLUSION

Although the science behind siting model development is established, few researchers have developed such models in an open way (e.g., documenting every stage of model development, engaging with community members). This mixed-method study has addressed this notable knowledge gap. While we have focused on rural palliative care in Canada, the process by which we have developed and refined our siting model is transferrable and can be applied to address other siting problems.

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.

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.

Out-of-hours medical care for terminally ill patients: A survey of availability and preferences of general practitioners

BACKGROUND

Continuity of care is one of the core values of good medical care for terminally ill patients. The availability of one's own general practitioner (GP) out of hours is regarded as important for personal continuity. Few data are available about the extent of out-of-hours care given by GPs to their terminally ill patients.

AIM

The objective of this study was to determine to which level GPs are available out of hours for their own terminally ill patients and to elicit what factors are relevant to this availability.

DESIGN AND SETTING

The research questions were investigated using a cross-sectional study of Dutch GPs. A questionnaire was sent to a random sample of 691 Dutch GPs.

RESULTS

The response rate was 47% (n = 327). Of the respondents, 86% was willing to provide out-of-hours care for their own terminally ill patients. These figures are higher than reported in previous studies. This study shows that out-of-hours availability correlates most strongly with the GPs' perception of duties of care. Availability is negatively influenced if the GP is in a salaried job, if he or she works in a city based practice, or if home is far from the practice. A correlation between age, sex, and experience of GPs and availability for out-of- hours care for their terminally ill patients was not confirmed.

CONCLUSIONS

The reported out-of-hours availability of GPs for terminally ill patients is still high. GPs' perception of their duty of care might change in the next generations, and the increasing number of salaried GPs, living far from their practice, might threaten out-of-hours availability for terminally ill patients. GPs' perception of their duty of care might change in the next generations, and the increasing number of salaried GPs living far from their practice might threaten out-of-hours availability for terminally ill patients.

Development of a rural palliative care program in the Calgary Zone of Alberta Health Services

Specialized rural models of palliative care are greatly needed to address the challenges rural communities face in providing palliative care services and to ensure that their unique strengths and needs are considered. In late 2005, a Rural Palliative Care Program was developed to support primary care providers in delivering palliative care to patients in rural communities outside of Calgary, Alberta, Canada. The program was grounded in the needs of individual communities, incorporated integral roles for local champions, and adopted pre-existing, accepted rural structures and processes. Needs and gaps in rural palliative care service delivery were identified and prioritized. The following actions were taken to address the top six priorities: 1) more accessible palliative care education opportunities with a rural focus were provided to health care professionals; 2) linkages with rural and urban resources were strengthened and access to specialists and procedures was improved; 3) strategies were implemented to improve psychosocial support for patients and families; 4) resources were developed to facilitate rural home deaths; 5) opportunities were expanded for education and utilization of volunteers; and 6) a mobile specialist consultation team was developed to support rural health care professionals and their patients in their rural communities. In its first four years, the team consulted on 640 patients, nearly three-quarters of whom died in their rural communities. Rather than imposing an urban outreach strategy, the development of a rural-based program through respectful engagement of local providers has proven to be crucial to the success of this rural palliative care program.

Exploring the community pharmacist's role in palliative care: focusing on the person not just the prescription

OBJECTIVE

Changes in health care provision have led to an emphasis on providing end of life care within the home. community pharmacists are well positioned to provide services to community-based palliative care patients and carers.

METHODS

A multiple qualitative case study design was adopted. A total of 16 focus groups and 19 interviews with pharmacists, nurses, general practitioners and carers were undertaken across metropolitan and regional settings in Western Australia, New South Wales, Queensland and Victoria. Data were analysed thematically using a framework that allowed similarities and differences across stakeholder groups and locations to be examined and compared.

RESULTS

Three main themes emerged: effective communication; challenges to effective communication; and: towards best practice, which comprised two themes: community pharmacists' skills and community pharmacists' needs.

DISCUSSION

A key component of the provision of palliative care was having effective communication skills. Although community pharmacists saw an opportunity to provide interpersonal support, they suggested that they would need to develop more effective communication skills to fulfil this role.

CONCLUSION

There is clear need for continuing professional development in this area - particularly in communicating effectively and managing strong emotions.

PRACTICE IMPLICATIONS

Community pharmacists are willing to support palliative care patients and carers but need education, support and resources.

Issues in rural palliative care: views from the countryside

CONTEXT

Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation.

PURPOSE

To better understand experiences and issues related to rural palliative care.

METHODS

Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique.

FINDINGS

Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care.

CONCLUSION

Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

'Heated political dynamics exist ...': examining the politics of palliative care in rural British Columbia, Canada

Palliative care is delivered by a number of professional groups and informal providers across a range of settings. This arrangement works well in that it maximizes avenues for providing care, but may also bring about complicated 'politics' due to struggles over control and decision-making power. Thirty-one interviews conducted with formal and informal palliative care providers in a rural region of British Columbia, Canada, are drawn upon as a case study. Three types of politics impacting on palliative care provision are identified: inter-community, inter-site, and inter-professional. Three themes crosscut these politics: ownership, entitlement, and administration. The politics revealed by the interviews, and heretofore underexplored in the palliative literature, have implications for the delivery of palliative care. For example, the outcomes of the politics simultaneously facilitate (e.g. by promoting advocacy for local services) and serve as a barrier to (e.g. by privileging certain communities/care sites/provider) palliative care provision.

A protocol for determining differences in consistency and depth of palliative care service provision across community sites

Numerous accounts document the difficulty in obtaining accurate data regarding the extent and composition of palliative care services. Compounding the problem is the lack of standardisation regarding categorisation and reporting across jurisdictions. In this study, we gathered both quantitative and spatial--or geographical--data to develop a composite picture that captures the extent, composition and depth of palliative care in the Canadian province of British Columbia (BC). The province is intensely urban in the southwest and is rural or remote in most of the remainder. For this study, we conducted a detailed telephone survey of all palliative care home care teams and facilities hosting designated beds in BC. We used geographic information systems to geocode locations of all hospice and hospital facilities. In-home care data was obtained individually from each of five BC regional health authorities. In addition, we purchased accurate road travel time data to determine service areas around palliative facilities and to determine populations outside of a 1-hour travel time to a facility. With this data, we were able to calculate three critical metrics: (i) the population served within 1 hour of palliative care facilities--and more critically those not served; (ii) a matrix that determines access to in-home palliative care measured by both diversity of professionals as well as population served per palliative team member; and (iii) a ranking of palliative care services across the province based on physical accessibility as well as the extent of in-home care. In combination, these metrics provide the basis for identifying areas of vulnerability with respect to not meeting potential palliative care need. In addition, the ranking provides a basis for rural/urban comparisons. Finally, the protocol introduced can be used in other areas and provides a means of comparing palliative care service provision amongst multiple jurisdictions.

Collaborating or co-existing: a survey of attitudes of medical oncologists toward specialist palliative care

Patients with advanced cancer often have complex care needs requiring collaboration between medical oncology and palliative care providers. Little is known about how effective and acceptable such collaboration is to medical oncologists. Attitudes of Australian medical oncologists toward collaboration with specialist palliative care services were investigated using a Web-based survey. Descriptive statistics and attitude indices were calculated and a thematic content analysis performed. One hundred and fifteen respondents (78 medical oncologists, 37 trainees) completed the survey (response rate 30.3%). Positive attitudes toward specialist palliative care involvement were expressed with most respondents preferring concurrent rather than sequential models of care (94.8%, n = 109). Reported barriers to collaboration included reluctance for referral by patients (minor 60.9%, n = 70; major 8.7%, n = 10) or families (minor 67%, n = 77; major 7%, n = 8), a lack of inpatient beds (minor 27%, n = 31; major 34.8%, n = 40) and inadequate resources for specialist palliative care to take some referrals (minor 30.4%, n = 35; major 30.4%, n = 35). There was no difference in attitude indices for those who had completed a palliative care rotation during their training (33%, n = 38) and those who had not. Suggestions for improvement in collaboration focused around four areas - improved resources, improved multidisciplinary links, mutual respect and understanding, and consistency in service provision. This study is the first to specifically investigate the views of Australian medical oncologists toward collaboration with specialist palliative care. While positive attitudes have been expressed, identified barriers to collaboration need attention.

Visioning for secondary palliative care service hubs in rural communities: a qualitative case study from British Columbia's interior

Background

As the populations of many developed nations continue to age at rapid rates it is becoming increasingly important to enhance palliative care service delivery in order to meet anticipated demand. Rural areas face a number of challenges in doing this, and thus dedicated attention must be given to determining how to best enhance service delivery in ways that are sensitive to their particular needs. The purposes of this article are to determine the vision for establishing secondary palliative care service hubs (SPCH) in rural communities through undertaking a case study, and to ascertain the criteria that need to be considered when siting such hubs.

Methods

A rural region of British Columbia, Canada was selected for primary data collection, which took place over a five-month period in 2008. Formal and informal palliative care providers (n = 31) were interviewed. A purposeful recruitment strategy was used to maximize occupational and practice diversity. Interviews were conducted by phone using a semi-structured guide. Interviews were audio recorded and transcribed verbatim. Data were managed using NVivo8™ software and analyzed thematically, using investigator triangulation to strengthen interpretation.

Results

Four themes emerged from the dataset: (1) main SPCH features; (2) determining a location; (3) value-added outcomes; and (4) key considerations. It was found that participants generally supported implementing a SPCH in the rural region of focus. Several consistent messages emerged, including that: (1) SPCHs must create opportunities for two-way information exchange between specialists and generalists and communities; (2) SPCHs should diffuse information and ideas throughout the region, thus serving as a locus for education and a means of enhancing training opportunities; and (3) hubs need not be physical sites in the community (e.g., an office in a hospice or hospital), but may be virtual or take other forms based upon local needs.

Conclusion

Visioning innovation in the provision of palliative care service in rural communities can be enhanced by consultation with local providers. Interviews are a means of determining local concerns and priorities. There was widespread support for SPCH coupled with some uncertainty about means of implementation.

Rural Palliative Care: A Comprehensive Review

Abstract Background: Access to integrated, palliative care regardless of location of residence is a palliative care standard yet we know such access is limited for those living in rural and remote settings. As a beginning step in the development of research aimed at informing policy and program development, a comprehensive review of the state of knowledge regarding palliative care in rural contexts is required. Purpose: To identify, evaluate and synthesize the published literature on rural palliative care. Design: Comprehensive review. Methods: Computer searches were conducted on PubBMed, ISI Web of Science, PsycInfo, CINAHL, and Ageline using the search terms palliative care, hospice, terminal care, end-of-life care, end-of-life, and rural or remote. Results: One hundred fifty-eight studies were retrieved. After screening using relevance and quality criteria, 79 studies were included in the review. Studies were grouped by subject matter into one of three categories: patient and caregiver perspectives; professional attitudes, knowledge and practice issues; and health care services. Conclusion: The body of research literature is small and eclectic, which means there is little strong evidence to inform palliative policy and service development in rural settings. Coordinated programs of research are clearly required to develop a body of knowledge that is adequate to support effective service and policy development.

A method to determine spatial access to specialized palliative care services using GIS

Background

Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular.

Methods

Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care.

Results

Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care.

Conclusion

Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners – and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.

Growing old and getting sick: maintaining a positive spirit at the end of life

End of life throws up significant mental health challenges. A high proportion of people in the terminal stages of illness experience depressive symptoms. This paper integrates a theory of hierarchy of human needs and empirical research describing experiences of grief and depression in terminal illness, to develop a model of care aimed at reducing depression and suffering. This care attends to physical, psychological, social and spiritual aspects, taking into account the concerns of patients and their families. Professional help can be offered to patients to restore dignity and hope, strengthen their ways of coping, and encourage social connections. To offer this, a well-resourced and coordinated, multidisciplinary and skilled workforce is needed.