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.

PAL-MED CONNECT ®: a telephone consultation hotline for palliative medicine questions

BACKGROUND

Community physicians are often ill-prepared for the management of complex symptoms. With a shortage of board certified physicians in palliative medicine to assist, the result is a lack of access to critical pain and symptom management expertise to care for seriously ill Californians. We report on a palliative medicine telephone hotline available to health care professionals.

METHODS

San Diego Hospice and The Institute for Palliative Medicine received a grant to provide a telephone hotline for health care professionals to assist in answering clinical questions relating to palliative care. An extensive marketing campaign was initiated to publicize the service. Information from the calls was collected over a 2.5-year period. The data included referral source, geographic area, diagnosis, and reason for call. Satisfaction surveys were sent following each call.

RESULTS

During the first 2.5 years of operation 498 calls were recorded. Although marketing was directed within the state of California, the majority of calls originated outside the state after the first year (66%). Approximately 43% of calls came from physicians, followed by 22% from registered nurses, 15% from nurse practitioners, and 6% from pharmacists. Nearly half of the calls were received from repeat callers. The most frequent topics for callers were related to pain and symptom management (29%), followed by hospice care (21%), medication dosing, and general palliative care (14% each). Ninety-five percent of the callers completed the satisfaction survey with 89% likely to use the service again.

CONCLUSIONS

The hotline proved to be a valuable resource for health care providers caring for patients requiring palliative care as evidenced by the steady increase in the number of calls over the initial 2.5 years of operation. Future research on how the information directly impacted patient care might generate data to support the continuation of this service via partnerships with other organizations.

What influences the willingness of community physicians to provide palliative care for patients with terminal cancer? Evidence from a nationwide survey

OBJECTIVE

Community physicians have a vital role in delivering palliative care, yet their willingness and factors that influence its provision have rarely been explored. Our aims were to identify the willingness of community physicians to provide palliative care for patients with terminal cancer and to investigate the factors that influence their willingness to provide such care.

METHODS

Through a structured questionnaire, this nationwide study surveyed 708 community physicians who were potential pilots to provide palliative care. Four hundred and ten valid questionnaires (58.0%) were retrieved and analysed.

RESULTS

The majority of respondents expressed a willingness (92.4%) to provide palliative care if they encountered patients with terminal cancer. However, they would limit their services to consultation (83.4%) and referral (86.8%), and were less likely to see patients and prescribe medicine (62.0%), to provide phone follow-ups (45.6%), to provide home visits (42.2%) or to offer bereavement care for the family (35.1%). The results of stepwise logistic regression analysis for the willingness to provide home visits showed that 'less perception of barriers', 'family medicine specialist' and 'older than 50 years' significantly predicted higher willingness, while 'female' predicted lower willingness. There was no significant association between the willingness and the knowledge score.

CONCLUSIONS

Community physicians' beliefs and experience in palliative care rather than their knowledge influence their willingness to provide palliative care for patients with terminal cancer. Only through active participation in the real-world clinical setting and active health policy administration can community physicians overcome obstacles to providing palliative care.

A shared care model pilot for palliative home care in a rural area: impact on symptoms, distress, and place of death

CONTEXT

Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs.

OBJECTIVES

To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death.

METHODS

An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models.

RESULTS

Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed.

CONCLUSION

Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.

Palliative care for older people - exploring the views of doctors and nurses from different fields in Germany

Background

Providing appropriate palliative care for older people is a major task for health care systems worldwide, and up to now it has also been one of the most neglected. Focusing on the German health care system, we sought to explore the attitudes of health professionals regarding their understanding of palliative care for older patients and its implementation.

Methods

In a qualitative study design, focus groups were established consisting of general practitioners, geriatricians, palliative care physicians, palliative care nurses and general nurses (a total of 29 participants). The group discussions were recorded, transcribed, coded and analysed using the methodological approach of Qualitative Description.

Results

Deficiencies in teamwork and conflicting role definitions between doctors and nurses and between family practitioners and medical specialists were found to be central problems affecting the provision of appropriate palliative care for older people. It was emphasized that there are great advantages to family doctors playing a leading role, as they usually have the longest contacts to the patients. However, the professional qualifications of family doctors were to some extent criticized. The general practitioners for their part criticized the increasing specialization on the field of palliative care. All groups complained that the German compensation system gives insufficient consideration to the time-consuming care of older patients, and about excessive bureaucracy.

Conclusion

General practitioners are the central health professionals in the delivery of palliative care for older people. They should however be encouraged to involve specialized services such as palliative care teams where necessary. With the German health care reform of 2007, a legal framework has been created that allows for this. As far as its realization is concerned, it must be ensured that the spotlight remains on the needs of the patients and not on policy conflicts and rivalries between health care professionals. Older people might particularly benefit if "talking" medicine and time-consuming care were properly catered for, financially and organizationally, in the health care system.

Palliative care telephone consultation: who calls and what do they need to know?

BACKGROUND

Access to expertise in palliative management in areas not served by palliative care consultants is an ongoing challenge. This study examines a unique service offered in British Columbia: a 24-hour telephone hotline available to physicians, nurses, and pharmacists across the province.

METHODS

Records of calls to the hotline over 4 years were collected. Call data included information on the caller, patient, and problem. The resulting database was analyzed for trends, including cross-tabulations to look for associations between call characteristics.

RESULTS

Six hundred ninety-two calls were included. A large variety of topics were addressed in significant numbers, ranging from symptom control to ethical concerns. The primary reason for calls to the line was pain management, followed by gastrointestinal symptoms such as nausea, diarrhea, and bowel obstruction. Patients with cancer diagnoses dominated the call volume; lung, colon, breast, prostate, and pancreatic cancer were the most common specific diagnoses. The majority of calls, when analyzed by population, came from areas with significant rural populations.

CONCLUSION

British Columbia's Palliative Care Hotline provides a valuable service that has been utilized province-wide with increasing frequency over the 6 years it has been in operation. It serves a variety of professionals and significant number of patients. Rural communities utilize the service with the most frequency, indicating the support needed in these communities. Similar services should be considered in other jurisdictions.

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.

Telephone consultation in palliative care for cancer patients: 5 years of experience in The Netherlands

GOALS OF WORK

To analyze cancer patient-related consultations of a telephone helpdesk (TH) for palliative care over a period of 5 years in the region of Utrecht, The Netherlands.

MATERIALS AND METHODS

A descriptive analysis was performed of consultations over a period of 5 years (2001-2006). The discipline and location of requesting professionals, patient characteristics, reasons for calling, symptoms, palliative care problems and needs for support were registered.

MAIN RESULTS

A total of 1,794 consultations were analyzed. There was an increasing number of consultations during the study period. Of the patients, 51% were male and their median age was 65 years (range 0-104). Eighty-four percent were treated at home by their general practitioner. Two thirds of the patients had a life expectancy <4 weeks. Most questions referred to pain (49%), delirium (20%), nausea and vomiting (16%) and dyspnea (12%). The median number of symptoms was 1 (0-6). Of the questions, 54% were related to pharmacological problems, 19% to psychological problems and 21% to the organization of care. Of the requesting professionals, 17% asked for support for themselves. Of the consultations, 14% were related to end-of-life issues: palliative sedation (11%) and euthanasia (3%).

CONCLUSION

After more than 5 years, the 24-h telephone consultation service fulfills a need for general practitioners dealing with daily dilemmas in palliative care treatment for cancer patients at home during the last period of their life.

Systematic review of educational interventions in palliative care for primary care physicians

BACKGROUND

A literature review of educational interventions in palliative care (PC) for primary care physicians (PCP) was performed, to evaluate its impact in changing professional practice.

METHODS

Studies undertaking any educational intervention in PC by PCP, published between 1966 and February 2005, identified through Medline, EMBASE, Cochrane Database of Systematic Reviews and Clinical Trials, Educational Resources Information Centre, Research and Development Resource Base in Continuing Medical Education, Spanish Medical Index, using a combined text word and MESH heading search strategy.

RESULTS

Eighteen articles were included with 1653 physicians. Educative methods were: role model training, small group discussions, and distribution of guidelines. Quality of the studies was low. Opioids prescription improved in two studies. Discrepancies were shown between the perception of PCP in symptom management, determined through questionnaires, and the data concerning opioids prescription. Knowledge improved in all studies. Some benefit of multifaceted approach was stated. Carers were satisfied, in general, with the PCP care, but dissatisfied with patients' pain control.

CONCLUSION

PC education for PCP is poorly studied. Adequate research designs are necessary in future studies with objective outcomes and patient opinion.

A Community Needs Assessment for Palliative Care Services from a Hospice Organization

BACKGROUND

Palliative care is described as comprehensive care focused on preventing or relieving physical, emotional, psychological, and spiritual suffering in patients with life-threatening illnesses. As national interest in increasing access to palliative care grows, hospice organizations may consider expanding their missions to provide palliative care to individuals with chronic and life-limiting illnesses who do not meet traditional hospice criteria. Before expanding operations, hospice organizations must know if there is need and support within the communities they serve.

OBJECTIVE

The purpose of this study was to assess perceived need for palliative care services in a small metropolitan area in the Midwest served by a nonprofit community-based hospice organization.

DESIGN

A survey approach was used.

SETTINGS/SUBJECTS

Surveys were distributed to health care professionals and lay individuals in the community by mail or in person. A total of 576 surveys were distributed; 195 were completed and returned.

RESULTS

While the majority of professionals reported being comfortable providing palliative care, services were not perceived as widely available. Both health care professional and lay respondents knew someone who could benefit from palliative care services and believed it would be helpful to develop or increase palliative care for persons with chronic illnesses who are not yet terminally ill. A majority of professionals reported they were willing to refer patients for services, but were concerned that patients would be hesitant to accept such care from a hospice organization. Lay individuals indicated they would be willing to accept such services, particularly if insurance covered the cost.

CONCLUSIONS

Several issues need further exploration before hospice organizations expand their missions.

Palliative care in Irish nursing homes: the work of community clinical nurse specialists

AIM

to assess the current level of input from community-based clinical nurse specialists in palliative care into nursing homes in the Republic of Ireland.

METHOD

a national survey was undertaken with questionnaires distributed via the National Council for the Professional Development of Nursing and Midwifery database. The total population was 114 community-based clinical nurse specialists in palliative care.

FINDINGS

63 completed questionnaires were returned achieving a 55% response rate. All respondents had undertaken work with nursing homes. The main focus of interactions with nursing homes was on pain and symptom management and this was often provided by telephone. The majority of nurses were involved exclusively in care of patients with cancer, although 40% of respondents cared for patients with non-malignant diseases.

CONCLUSIONS

As populations age and more people end their lives in residential care settings, this area of care has increasing relevance. The dissemination of palliative care best practice would ensure that all patients, regardless of their diagnosis, receive the benefits of palliative care at the end of life. Clinical nurse specialists are ideally placed to provide education and support to nursing homes and other residential care settings for older people.

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.

Time expenditure in patient-related care provided by specialist palliative care nurses in a community hospice service

Although the importance of specialist palliative care in home care programmes for terminally ill patients is well known, German community hospice services did not begin to employ nurses who had specialized in palliative care until the early 1990s. The general tasks of these nurses are sufficiently well defined, but no comprehensive data of their daily workload are available in Germany to date. The present article examines time expenditure in direct patient-related care at the community-based hospice service in Mainz, Germany, by analysing time registration sheets concerning 351 patients who received care from January 2000 until December 2002. Fifty-five per cent of care time spent on each individual patient was in direct contact with that patient and/or his or her relatives, 20% of the time was spent on networking and other related tasks, 17% on travelling and 8% on bereavement counselling. Activities in direct patient contact were allotted to pain and symptom control (36.4%) and psychosocial support of the patient (32.4%) or his or her relatives (27.1%), whereas nursing issues played a minor role (4%).

District nurse involvement in providing palliative care to older people in residential care homes

Although less than 15% of older people in care homes die of a terminal disease such as cancer, many more die following a period of slow deterioration. In the UK, residents of care homes receive their nursing care from primary healthcare providers. This article reports on a study that describes how district nurses and care home managers define their responsibilities when caring for residents who are dying. The findings presented are from a detailed survey of 89 district nurse team leaders and 96 care home managers. District nurses were the most frequent health professionals visiting care homes, but less than half reported involvement in palliative care. The differing priorities and perceptions of participants regarding what constituted nursing and personal care influenced older people's access to palliative care services. Furthermore, the organization of care and the stability of the care home workforce affected participants' ability to establish ongoing supportive working relationships. It is argued that unless there is an organizational review of current practice, older people will continue to have unequal access to generalist and specialist palliative care.

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

"A planning guide": Developing a consensus document for palliative care service provision

Over the past 30 years, palliative care services have developed in an ad-hoc way in Australia and around the world. Community expectations for palliative care have grown in recent years. As palliative care has evolved, the World Health Organization definition of palliative care has changed substantially. The changes challenge those who are involved in planning, funding and provision of services to meet new expectations. Many services have not attracted adequate nursing, medical and allied health resources to provide interdisciplinary palliative care. A national consensus document ("a planning guide") has been developed in consultation with key stakeholders and organisations. It outlines the minimum needs for service provision, independent of fundholders and models of service delivery.

An analysis of calls to an out-of-hours palliative care advice line

An advice line was set up by a specialist palliative care hospice to improve the provision of out-of-hours palliative care to primary care teams, i.e. from 17.00 to 09.00 h during the week and at weekends and bank holidays. A senior member of nursing staff or medical staff answered all calls. During the first year of operation, 98 calls were received. The majority of callers were GPs (55%) and community nurses (34%). The advice requested was largely related to management of pain and the use of opiates, e.g. breakthrough dose of opiates and conversion of drugs to syringe drivers. Recommendations from this study include the provision of continuing education on management of terminally ill patients, and improved communication between primary care teams, providers of out-of-hours primary care and specialist palliative care teams.

Hospice and primary care physicians: attitudes, knowledge, and barriers

Underuse of hospice services is a significant problem in the United States. Primary care physicians constitute an increasing referral base and have been hypothesized to be important barriers to increased use. We conducted a mail survey of 131 primary care physicians (overall response rate of 72 percent), examining their attitudes toward, knowledge about, and perceived benefits and barriers to hospice care. Physicians demonstrated very favorable attitudes towards hospice. They had correct knowledge about most aspects of hospice, and, where they did not, they were far more likely to be uncertain than erroneous. Primary care physicians perceived many benefits to hospice care and identified patient and family readiness as the major barrier to earlier hospice referrals. A significant subgroup had concerns about problems in interacting with hospices. There were very few differences between family practitioners and general internists. These findings have many implications for directing collaborative efforts between primary care physicians and hospices to improve end-of-life care.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

Survey of primary care physicians and home care clinicians

CONTEXT

Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients.

OBJECTIVE

To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network.

DESIGN

Mail survey.

SETTING

Boston.

PARTICIPANTS

Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies.

MEASUREMENTS

Provider responses

RESULTS

Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary.

CONCLUSIONS

PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.

Physicians and hospice care: attitudes, knowledge, and referrals

Underutilization of hospice care continues to be a public health issue in the United States. Physician barriers related to incorrect knowledge and unfavorable attitudes have been hypothesized as part of the explanation. We conducted a mail survey of 264 area physicians, obtaining a response rate of 72% (n = 190). The survey examined attitudes toward, knowledge about, and perceptions of benefits and barriers to hospice care. Physicians demonstrated very positive attitudes toward hospice. They had correct knowledge about some aspects of hospice, but were uncertain about correct answers on the majority of items. They had erroneous knowledge on few items. Physicians perceived many benefits to hospice care, and identified patient and family readiness as the major barriers to earlier hospice referrals. Demographic and practice variables were related to responses on few of the survey items. These findings have many implications for outreach strategies for physicians as well as future research.

Communication issues for the interdisciplinary community palliative care team

This paper discusses the findings of a critical study that examined the communication patterns between nurses and general practitioners (GPs) providing palliative care in Australia. Interviews and focus groups involved 40 palliative care nurses who worked in the three settings of care: community, hospice and hospital. Issues that impeded effective communication strategies between palliative care nurses and GPs were networking, case management, multiple service providers, lack of standardized documentation and formal tracking of clients, along with difficulties in transmission of relevant practice knowledge. Supporting strategies for effective formal modes of communicating and reporting are described.

An audit of out-of-hours advice services provided by hospice staff

For those giving and receiving health care there will always be problems and queries which occur outside of normal office hours. Palliative care is no exception. It was found that Queenscourt Hospice in Southport was being used as an accessible point of contact for specialist palliative care advice by patients, relatives and health professionals. In response, an audit was undertaken to monitor the frequency and substance of the many drop-in visits and telephone calls to the hospice. The results showed that almost half of the calls/visits received are outside office hours. This article describes the nature of the calls and the advice offered by the staff taking the call. As the majority of the 'out-of-hours' calls/visits were taken by nursing staff, it was necessary for them to draw on their specialist palliative care knowledge and communication skills to make an assessment of how best to deal with each situation. As a result of the audit, several organizational and educational initiatives have been developed to further improve the service offered.