How do GPs identify a need for palliative care in their patients? An interview study

General practitioners and palliative care practices: a better knowledge of specific services is still needed

BACKGROUND

France allows deep sedation for pain relief, but not for euthanasia. In anticipation of an increase in home-based palliative care, the role of general practitioners is central to the design of outpatient palliative care services. This study aimed to describe the knowledge, attitudes, and practices of general practitioners in mainland France regarding palliative and end of life care.

METHODS

This was a national descriptive cross-sectional study within the Sentinelles network. Self-report questionnaires were distributed to general practitioners between November 2020 and November 2021. A descriptive analysis was carried out.

RESULTS

Out of the 123 participating general practitioners, 84% had received academic training in palliative care (n = 104). While a significant majority (69%) expressed comfort in pain management, only a quarter (25%) declared that they were competent at indicating deep and continuous sedation for pain relief. Awareness of outpatient palliative care facilities close to their place of practice such as hospitalization at home was over 97% (n = 117/120). Awareness of hospital facilities, including identified palliative care beds on hospital wards and palliative care units, was lower (75% (n = 59/79) and 86% (n = 86/100), respectively).

CONCLUSIONS

Our results suggest that French general practitioners are reasonably aware of palliative care resources available. However, there is room for improvement, particularly in understanding hospital-based facilities. Furthermore, a quarter of the general practitioners expressed discomfort with deep and continuous sedation for pain relief, highlighting the need for increased training in this specific aspect of palliative and end of life care.

How family physicians introduce palliative care to patients with chronic illnesses

OBJECTIVE

Increasing numbers of Canadians living with complex, life-limiting conditions demand high-quality palliative care. Timely access to palliative care can help to reduce stress, improve quality of life, and provide relief for patients and their families. The purpose of this study is to explore the experiences of family physicians (FPs) regarding the decision and process of introducing palliative care to patients with chronic diseases.

METHODS

Interpretive description methodology was used to guide the investigation of the research question. Thirteen Calgary Zone FPs participated in individual interviews. Data was collected iteratively and analyzed using constant comparative analysis.

RESULTS

Analysis of interviews identified the overarching themes of dignity and empowerment, which describe the experience of FPs introducing palliative care to chronically ill patients. Four subthemes were woven throughout, including the art of conversation, therapeutic relationships, timing, and preparation of the patient and family.

DISCUSSION

While the benefits of palliative conversations are widely accepted, a deeper understanding of how FPs can be supported in developing this aspect of their practice is needed. Understanding their experience provides knowledge that can serve as a framework for future education, mentorship, and competency development.

Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-PALL): a qualitative interview study

BACKGROUND

Palliative care improves quality of life for people with life-threatening illnesses. There are longstanding inequalities in access to palliative care, with many people never identified as having palliative care needs, particularly frail older people, those with non-malignant disease, and people from ethnic minority backgrounds. Little is known about the process of identification of palliative care needs from a patient perspective.

AIM

To provide new understanding into patient views and experiences of the process of identification of palliative care needs, and to explore the impact of identification on health care, if any, from a patient perspective.

DESIGN AND SETTING

A qualitative interview study undertaken with patients and family carers in a major UK city.

METHOD

Semi-structured interviews were carried out with patients (and/or family carers) identified as being on general practice palliative care registers. An inductive thematic analysis was conducted to explore the data.

RESULTS

Eleven participants were recruited: eight patients and three family carers. The following three interrelated themes were identified: 1) misconceptions about palliative care and unshared prognostic uncertainty hinder the identification of palliative care needs; 2) a compassionate, timely approach is required for identification of palliative care needs, with or without an identification tool; and 3) identification of palliative care needs is beneficial where it leads to proactive holistic care.

CONCLUSION

A compassionate approach, sharing of prognostic uncertainty, and proactive primary care are key to timely, beneficial identification of palliative care needs. Future policy should ensure that identification is an adaptable, personalised process to meet the individual needs of people with advanced serious illnesses.

["The total time spent by the general practitioner decreases": The referring physician's view of a palliative day care clinic]

BACKGROUND

Palliative day-care clinics (PDCCs) can complement inpatient and outpatient specialized palliative care. Some studies have shown improvements in the patients'́ symptoms, functional level and psychological well-being, while others have not. This study aimed to document the experience of referring physicians with PDCCs.

METHOD

A postal questionnaire was sent to referring physicians between 11/2020 and 3/2021. The questionnaire included open and closed questions about professional background, symptom control, medical / psychosocial benefits for patients and challenges in the collaboration. Closed, 5-point scaled questions were analyzed descriptively with IBM SPSS Statistics 25®, open questions with a thematic content analysis using MAXQDA 2020®.

RESULTS

Of the 96 referring physicians contacted, 76 questionnaires were returned (79%), 73 of which could be analyzed. Most referring physicians were general practitioners (57%), followed by oncologists (28%). 12% had completed further training in palliative medicine and had been working with patients with palliative care needs for an average of almost 19 years. On average, they had referred 24 patients (range 1-200) to a PDCC. 93% said that inpatient stays were delayed or avoided by PDCCs. 97% were of the opinion that their patients achieved a (great or rather great) benefit from medical treatment, and 96% thought that they benefited (to a great or rather great degree) from psychosocial treatment. 58% said that their own time spent with patients treated at the PDCC had decreased. In addition, a total of 227 open comments on challenges in cooperation, suggestions for optimization, reasons for referring patients and general wishes for PDCCs were analyzed.

DISCUSSION

The high response rate to the questionnaires shows that PDCCs are of great importance to referring physicians. They consider the cooperation with PDCCs to be supportive and helpful for both themselves and their patients.

CONCLUSION

PDCCs make an important contribution to palliative care. Almost all respondents believe that treatment at a PDCC prevents or delays hospitalization.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Discussing prognosis and the end of life with patients with advanced cancer or COPD: A qualitative study

Objectives

To explore patients’ experiences and recommendations for discussions about their prognosis and end of life with their physicians.

Methods

Patients with advanced cancer or advanced chronic obstructive pulmonary disease (COPD) were enrolled in qualitative interviews, which were analyzed with a phenomenological and thematic approach.

Results

During interviews with fourteen patients (median age 64 years), we identified the following themes for discussion about prognosis and the end of life: topics discussed, the timing, the setting, physician–patient relationship, responsibilities for clinicians, and recommendations. Patients preferred the physician to initiate such discussion, but wanted to decide about its continuation and content. The discussions were facilitated by an established physician–patient relationship or attendance of relatives. Patients with cancer had had discussions about prognosis at rather clear-cut moments of deterioration than patients with COPD. Patients with COPD did not consider end-of-life discussions a responsibility of the pulmonologist. Patients recommended an understandable message, involvement of relatives or other clinicians, sufficient time, and sensitive non-verbal communication.

Conclusions

Patients appreciated open, sensitive, and negotiable discussions about prognosis and the end of life.

Practice implications

Patients’ recommendations could be used for communication training. Possible differences in the need for such discussions between patients with cancer or COPD warrant further research.

Integration of primary palliative care into geriatric care from the Indian perspective

The rising trend in the ageing population alongside social, cultural, and economic changes poses a major threat to the health care system in the country. Elderly population have dynamic and complex health care needs, are debilitated by the progressive chronic life-threatening diseases, and live a compromised quality of life. Palliative care, with its multifaceted approach, can provide respite to the elderly population. A decentralized approach in which palliative care is provided by the local community will ensure seamless continuity of care and care at an affordable cost. General practitioners or family physicians play a vital role in delivering primary palliative care to the elderly population in the community. An integrating primary palliative-geriatric care model will ensure that care is provided in alignment with the patients' and their families' wishes along the trajectory of the life-threatening illness and at the patients' preferred place. However, delivering primary palliative care in the community can be riddled with challenges at various levels, such as identification of patients in need of palliative care, interpersonal communication, addressing patients' and caregivers' needs, clarity in roles and responsibilities between general practitioner and family physicians and specialist palliative care teams, coordination of services with specialists, and lack of standard guidelines for palliative care referral. Various geriatric-palliative care models have been tested over the years, such as delivering palliative and end-of-life care for disease-specific conditions at specified care settings (home or hospice) and provision of care by different specialist palliative care teams and general practitioners or family physicians. Akin to the aforementioned models, the National Health Program in the country envisages to strengthen the integration of geriatric and palliative care. The integrated geriatric-palliative care model will ensure continuity of care, equitable distribution of service, impeccable inter-sectoral collaboration and care at an affordable cost.

Public Health Perspective of Primary Palliative Care: A Review through the Lenses of General Practitioners

The rising trend of chronic life-threatening illnesses is accompanied by an exponential increase in serious health-related suffering. Palliative care is known to ameliorate physical and psychosocial suffering and restore quality of life. However, the contemporary challenges of palliative care delivery, such as changing demographics, social isolation, inequity in service delivery, and professionalisation of dying, have prompted many to adopt a public health approach to palliative care delivery. A more decentralised approach in which palliative care is integrated into primary care will ensure that the care is available locally to those who need it and at a cost that they can afford. General practitioners (GPs) play a pivotal role in providing primary palliative care in the community. They ensure that care is provided in alignment with patients’ and their families’ wishes along the trajectory of the life-threatening illness and at the patient’s preferred place. GPs use an interdisciplinary approach by collaborating with specialist palliative care teams and other healthcare professionals. However, they face challenges in providing end-of-life care in the community, which include identification of patients in need of palliative care, interpersonal communication, addressing patients’ and caregivers’ needs, clarity in roles and responsibilities between GPs and specialist palliative care teams, coordination of service with specialists and lack of confidence in providing palliative care in view of deficiencies in knowledge and skills in palliative care. Multiple training formats and learning styles for GPs in end-of-life care have been explored across studies. The research has yielded mixed results in terms of physician performance and patient outcomes. This calls for more research on GPs’ views on end-of-life care learning preferences, as this might inform policy and practice and facilitate future training programs in end-of-life care.

General practitioners' evaluations of optimal timing to initiate advance care planning for patients with cancer, organ failure, or multimorbidity: A health records survey study

BACKGROUND

Appropriate timing to initiate advance care planning is difficult, especially for individuals with non-malignant disease in community settings.

AIM

To identify the optimal moment for, and reasons to initiate advance care planning in different illness trajectories.

DESIGN AND METHODS

A health records survey study; health records were presented to 83 GPs with request to indicate and substantiate what they considered optimal advance care planning timing within the 2 years before death. We used quantitative and qualitative analyses.

SETTING AND PATIENTS

We selected and anonymized 90 health records of patients who died with cancer, organ failure or multimorbidity, from a regional primary care registration database in the Netherlands.

RESULTS

The median optimal advance care planning timing according to the GPs was 228 days before death (interquartile range 392). This moment was closer to death for cancer (87.5 days before death, IQR 302) than for organ failure (266 days before death, IQR 401) and multimorbidity (290 days before death, IQR 389) (p < 0.001). The most frequently mentioned reason for cancer was "receiving a diagnosis" (21.5%), for organ failure it was "after a period of illness" (14.7%), and for multimorbidity it was "age" and "patients" expressed wishes or reflections' (both 12.0%).

CONCLUSION

The optimal advance care planning timing and reasons to initiate advance care planning indicated by GPs differ between patients with cancer and other illnesses, and they also differ between GPs. This suggests that "the" optimal timing for ACP should be seen as a "window of opportunity" for the different disease trajectories.

Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories

Background

Advance Care Planning (ACP) enables physicians to align healthcare with patients’ wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice.

Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice.

Methods

We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life.

Results

In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30–316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2–5) and extensive (median 5 items, IQR 2–7) ACP consultations.

Conclusion

Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for – and documentation of – ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care.

Care Professionals Manage the Future, Frail Older Persons the Past. Explaining Why Frailty Management in Primary Care Doesn't Always Work

Frailty management focuses on optimizing the physical and psychological functioning of older people with frail health through early risk identification and intervention in primary care. Such care programs demand a joint effort by primary care professionals and older persons, one in which professionals are expected to promote or facilitate self-management practices and older persons are expected to adhere to the professional advice. It is known that patients and professionals hold different perspectives on frailty, but we know little about how this may affect their cooperation in frailty management. In this article, we therefore study how different perspectives of older persons and their primary care professionals play a role frailty management in practice. Nine cases of frailty management were reconstructed through semi-structured interviews with older persons, their family doctor and practice nurse. Drawing from literature on managing complex problems, we analyzed how "factual" and "normative" orientations played a role in their perspectives. We observe that the perspectives of care professionals and older persons on frailty management were substantially different. Both actors "manage" frailty, but they focus on different aspects of frailty and interestingly, care professionals' rationale is future-oriented whereas older person's rationale past-oriented. Primary care professionals employed practices to manage the medical and social factors of frailty in order to prevent future loss. Older persons employed practices to deal with the psychological, emotional and social aspects of the different types of loss they already experienced, in order to reconcile with loss from the past in the present. These findings raise fundamental questions regarding the different perceptions of and priorities around not only care for frail older people in general, but also implied professional-patient relations and the value of a risk-management approach to care for older people with frail health. The distinction between these perspectives could help care professionals to better respond to older patients' preferences and it could empower older persons to voice preferences and priorities that might not fit within the proposed care program.

General practitioners' considerations when deciding whether to initiate end-of-life conversations: a qualitative study

BACKGROUND

End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life.

OBJECTIVE

To explore GPs' thought processes when deciding whether to initiate end-of-life discussions.

METHODS

A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors.

CONCLUSIONS

These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.

Palliative and End-of-Life Care: Vital Aspects of Holistic Diabetes Care of Older People With Diabetes

Palliative and end-of-life care and advance care planning are important components of holistic diabetes management, especially for older people with a long duration of diabetes and comorbidities who experience unpleasant symptoms and remediable suffering. Many diabetes clinicians do not have conversations about advance care planning with people with diabetes, often because they are reluctant to discuss these issues and are not familiar with palliative care. This article outlines palliative, terminal, and end-of-life care for older people with type 1 or type 2 diabetes and suggests when to consider changing the focus on tight blood glucose control to a focus on safety and comfort. It proposes strategies to incorporate palliative and end-of-life care into personalized holistic diabetes care, determined with older people with diabetes and their families through shared decision-making.

The views of physicians and nurses on the potentials of an electronic assessment system for recognizing the needs of patients in palliative care

Objectives

Patients in oncological and palliative care (PC) often have complex needs, which require a comprehensive treatment approach. The assessment of patient-reported outcomes (PROs) has been shown to improve identification of patient needs and foster adjustment of treatment. This study explores occupational routines, attitudes and expectations of physicians and nurses with regards to a planned electronic assessment system of PROs.

Methods

Ten physicians and nine nurses from various PC settings in Southern Germany were interviewed. The interviews were analysed with qualitative content analysis.

Results

The interviewees were sceptical about the quality of data generated through a patient self-assessment system. They criticised the rigidity of the electronic assessment questionnaire, which the interviewees noted may not fit the profile of all palliative patients. They feared the loss of personal contact between medical staff and patients and favoured in-person conversation and on-site observations on site over the potential system. Interviewees saw potential in being able to discover unseen needs from some patients. Interviewees evaluated the system positively in the case that the system served to broadly orient care plans without affecting or reducing the patient-caregiver relationship.

Conclusions

A significant portion of the results touch upon the symbolic acceptance of the suggested system, which stands for an increasing standardisation and technisation of medicine where interpersonal contact and the professional expertise are marginalized. The study results can provide insight for processes and communication in the run-up to and during the implementation of electronic assessment systems.

Palliative care in primary care: European Forum for Primary Care position paper

AIM

The aim of this position paper is to assist primary health care (PHC) providers, policymakers, and researchers by discussing the current context in which palliative health care functions within PHC in Europe. The position paper gives examples for improvements to palliative care models from studies and international discussions at European Forum for Primary Care (EFPC) workshops and conferences.

BACKGROUND

Palliative care is a holistic approach that improves the quality of life of patients and their families facing problems associated with terminal illness, through the prevention and relief of suffering by means of early identification and diligent assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual. Unfortunately, some Europeans, unless they have cancer, still do not have access to generalist or specialist palliative care.

METHODS

A draft of this position paper was distributed electronically through the EFPC network in 2015, 2016, and 2017. Active collaboration with the representatives of the International Primary Palliative Care Network was established from the very beginning and more recently with the EAPC Primary Care Reference Group. Barriers, opportunities, and examples of good and bad practices were discussed at workshops focusing on palliative care at the international conferences of Southeastern European countries in Ljubljana (2015) and Budva (2017), at regular conferences in Amsterdam (2015) and Riga (2016), at the WONCA Europe conferences in Istanbul (2015), Copenhagen (2016), and Prague (2017), and at the EAPC conference in Madrid (2017).

FINDINGS

There is great diversity in the extent and type of palliative care provided in primary care by European countries. Primary care teams (PCTs) are well placed to encourage timely palliative care. We collected examples from different countries. We found numerous barriers influencing PCTs in preparing care plans with patients. We identified many facilitators to improve the organization of palliative care.

How do hospital-based nurses and physicians identify the palliative phase in their patients and what difficulties exist? A qualitative interview study

BACKGROUND

Early start of palliative care improves the quality of life of eligible patients and their relatives. However, in hospital, patients who could benefit from palliative care are often not identified timely. The aim of this study is to assess how hospital-based nurses and physicians define the palliative phase, how they identify the palliative phase and what difficulties they face.

METHODS

Semi-structured interviews were held with ten nurses and 18 physicians working at seven hospitals in the Netherlands. Data was analysed using thematic analysis.

RESULTS

Nurses and physicians feel insecure about how to define the palliative phase and differentiate between an acute and extended phase. Great variation existed in what life expectancy is attributed to each phase. A variety of ways to identify the palliative phase were described: 1) Prognostication. 2) Treatment trade-off. 3) Assessment of patients' preferences and needs. 4) Interprofessional collaboration. Professionals base prognostication on their experience but also search for clinical indicators. When benefits of treatment no longer outweigh the negatives, this was considered an, albeit late, identification point. To start a conversation on a patients' palliative care needs was found to be difficult. Therefore, some respondents wait for patients to vocalize preferences themselves. Many professionals rely on interprofessional collaboration for identification, however uncertainty exist about responsibilities. Difficulties in identification occurred because of variance in definitions, unpredictability of non-oncological diseases, focus on treatment and difficulties in communication and collaboration.

CONCLUSION

These results provide insight into the challenges and difficulties hospital-based professionals experience in timely identification of patients with palliative care needs.

Predicting life expectancy with a long short-term memory recurrent neural network using electronic medical records

BACKGROUND

Life expectancy is one of the most important factors in end-of-life decision making. Good prognostication for example helps to determine the course of treatment and helps to anticipate the procurement of health care services and facilities, or more broadly: facilitates Advance Care Planning. Advance Care Planning improves the quality of the final phase of life by stimulating doctors to explore the preferences for end-of-life care with their patients, and people close to the patients. Physicians, however, tend to overestimate life expectancy, and miss the window of opportunity to initiate Advance Care Planning. This research tests the potential of using machine learning and natural language processing techniques for predicting life expectancy from electronic medical records.

METHODS

We approached the task of predicting life expectancy as a supervised machine learning task. We trained and tested a long short-term memory recurrent neural network on the medical records of deceased patients. We developed the model with a ten-fold cross-validation procedure, and evaluated its performance on a held-out set of test data. We compared the performance of a model which does not use text features (baseline model) to the performance of a model which uses features extracted from the free texts of the medical records (keyword model), and to doctors' performance on a similar task as described in scientific literature.

RESULTS

Both doctors and the baseline model were correct in 20% of the cases, taking a margin of 33% around the actual life expectancy as the target. The keyword model, in comparison, attained an accuracy of 29% with its prognoses. While doctors overestimated life expectancy in 63% of the incorrect prognoses, which harms anticipation to appropriate end-of-life care, the keyword model overestimated life expectancy in only 31% of the incorrect prognoses.

CONCLUSIONS

Prognostication of life expectancy is difficult for humans. Our research shows that machine learning and natural language processing techniques offer a feasible and promising approach to predicting life expectancy. The research has potential for real-life applications, such as supporting timely recognition of the right moment to start Advance Care Planning.

Rethinking End-of-Life Care and Palliative Care: Learning From the Illness Trajectories and Lived Experiences of Terminally Ill Patients and Their Family Carers

Lynn conceptualized end-of-life (EoL) care for patients with advanced chronic-progressive illnesses as a combination of life-preserving/palliative care, the palliative aspect gradually becoming the main focus as death approaches. We checked this concept by exploring the advanced-terminal illness trajectories of 50 patients. Strategies heralding active therapy exhaustion were the catalyst for a participant's awareness of terminality, but were not a decisive factor in the divergent EoL care pathways we detected. The terms life-preserving and palliative do not adequately capture EoL care pathways due to their conceptual ambiguity. Conversely, the concept of EoL care encompassing three palliative care modalities ( life-prolonging palliative therapy, restorative palliative care, and symptom-oriented [only] palliative care), each harboring a different blend of life-preserving and symptom-comforting aspects, proved adequate. These modalities could run serially, oscillatorily, or parallelly, explaining the divergent EoL care pathways. We suggest an adjustment of the model of Lynn and reconsider the traditional palliative care concept.

Advance care planning conversations with palliative patients: looking through the GP's eyes

Background

Although it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences.

Methods

Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis.

Results

Four themes were identified: ACP and society, the GP’s perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a ‘hot topic’. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy.

Conclusions

ACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP’s focus on the patient’s direction and the right not to know can be difficult, ACP has to be tailored to each individual patient.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0868-5) contains supplementary material, which is available to authorized users.

Palliative and end of life care of people with diabetes: Issues, challenges and strategies

Palliative and end of life care are essential, but largely overlooked, aspects of comprehensive, personalised diabetes care. Life expectancy is lower in people with diabetes than in the general population due to complications and comorbidities, especially those associated with obesity such as cardiovascular disease, frailty and cancer. This paper makes the case for early initiation of palliative care and proactive planning for end of life. Early use of palliative care improves symptom management, comfort and quality of life, and often improves function. Significantly, it reduces disease burden and unnecessary treatment. Prognostication is challenging, but tools such as the Gold Standard Framework and diabetes-related indicators of reduced life expectancy can help identify those at high risk one year mortality. Skilled conversations, underpinned by an evidence-based framework, are a critical component in helping people with diabetes, and their families, discuss these complex issues and make appropriate advance care plans based on their values and preferences.

Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners

BACKGROUND

Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice.

METHODS

We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation.

RESULTS

In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up.

CONCLUSION

We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.

Adding a second surprise question triggers general practitioners to increase the thoroughness of palliative care planning: results of a pilot RCT with cage vignettes

Background

In our aging society, palliative care should be a standard component of health care. However, currently it is only provided to a small proportion of patients, mostly to those with cancer, and restricted to the terminal phase. Many general practitioners (GPs) say that one of their most significant challenges is to assess the right moment to start anticipatory palliative care. The “Surprise Question” (SQ1: “Would I be surprised if this patient were to die in the next 12 months”?), if answered with “no”, is an easy tool to apply in identifying patients in need of palliative care. However, this tool has a low specificity. Therefore, the aim of our pilot study was to determine if adding a second, more specific “Surprise Question” (SQ2: “Would I be surprised if this patient is still alive after 12 months”?) in case SQ1 is answered in the negative, prompts GPs to plan for anticipatory palliative care.

Methods

By randomization, 28 GPs in the south-eastern part of the Netherlands were allocated to three different groups. They all received a questionnaire with four vignettes, respectively representing patients with advanced organ failure (A), end stage cancer (B), frailty (C), and recently diagnosed cancer (D). GPs in the first group did not receive additional information, the second group received SQ1 after each vignette, and the third group received SQ1 and SQ2 after each vignette. We rated their answers based on essential components of palliative care (here called RADIANT score).

Results

GPs in group 3 gave higher RADIANT scores to those vignettes in which they would be surprised if the patients were still alive after 12 months. In all groups, vignette B had the highest mean RADIANT score, followed by vignettes A and C, and the lowest on vignette D. Seventy-one percent of GPs in groups 2 and 3 considered SQ1 a helpful tool, and 75% considered SQ2 helpful.

Conclusions

This innovative pilot study indicates that the majority of GPs think SQ2 is a helpful additional tool. The combination of the two “Surprise Questions” encourages GPs to make more specific plans for anticipatory palliative care.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0312-6) contains supplementary material, which is available to authorized users.

Early Identification of Patients in Need of Palliative Care in Slovenian General Practice

Background

To help general practitioners (GPs) in early identification of patients with palliative care (PC) needs, this pilot study aimed to determine the potential of the combined original surprise question (SQ1) ('Would I be surprised if this patient died within the next 12 months?') and the second surprise question (SQ2) ('Would I be surprised if this patient was still alive after 12 months?'). We hypothesized that answering these SQs would trigger them to make a multidimensional care plan.

Methods

26 Slovenian GPs, randomized into 4 groups, were invited to write a care plan for each of the four patients described in case vignettes (2 oncologic, 1 organ failure and 1 frailty case). GPs in group 1 were only asked to write a care plan for each patient. GPs in group 2 answered SQ1 and GPs in groups 3 and 4 answered SQ1 and SQ2 before writing the care plan. The type and number of PC aspects mentioned in the respective care plans were quantified into a numeric RADboud ANTicipatory (RADIANT) score.

Results

Mean RADIANT scores in groups 1-4 were 2.2, 3.6, 2.5 and 3.1, respectively. When comparing the different vignettes, vignette B (terminal oncologic patient) scored best (3.6). Mean RADIANT scores in groups 3 and 4 were slightly higher for GPs who would be surprised compared to GPs who would not be surprised if the patient was still alive in 12 months.

Conclusion

The combined SQs were considered helpful in the early identification of patients in need of PC in Slovenian general practice.

Improving palliative care provision in primary care: a pre- and post-survey evaluation among PaTz groups

BACKGROUND

In PaTz (PAlliatieve Thuis Zorg, palliative care at home), modelled after the Gold Standards Framework, GPs and community nurses meet on a regular basis to identify patients with palliative care needs (the PaTz register), and to discuss care for these patients.

AIM

To study the effects of the implementation of PaTz, and provide additional analyses on two important elements: the PaTz register and patient discussions.

DESIGN AND SETTING

A pre- and post-evaluation among Dutch GPs (n = 195 before the start of PaTz; n = 166, 1 year after the start of PaTz). The GPs also provided data on recently deceased patients (n = 460 before the start of PaTz; n = 305 14 months after the start of PaTz).

METHOD

GPs from all 37 PaTz groups filled in questionnaires. Pre- and post-test differences were analysed using multilevel analyses to adjust for PaTz group.

RESULTS

Identification of patients with palliative care needs was done systematically for more patients after implementation of PaTz compared with before (54.3% versus 17.6%). After implementation, 64.8% of deceased patients had been included on the PaTz register. For these patients, when compared with patients not included on the PaTz register, preferred place of death was more likely to be known (88.1% of patients not on the register and 97.3% of deceased patients included on the register), GPs were more likely to have considered a possible death sooner (>1 month before death: 53.0% and 80.2%), and conversations on life expectancy, physical complaints, existential issues, and possibilities of care occurred more often (60.8% and 81.3%; 68.6% and 86.1%; 22.5% and 34.2%; 60.8% and 84.0%, respectively).

CONCLUSIONS

Implementation of PaTz improved systematic identification of palliative care patients within the GP practice. Use of the PaTz register has added value.

How do treatment aims in the last phase of life relate to hospitalizations and hospital mortality? A mortality follow-back study of Dutch patients with five types of cancer

Purpose

The purpose of this study is to describe and compare the relation between treatment aims, hospitalizations, and hospital mortality for Dutch patients who died from lung, colorectal, breast, prostate, or pancreatic cancer.

Methods

A mortality follow-back study was conducted within a sentinel network of Dutch general practitioners (GPs), who recorded the end-of-life care of 691 patients who died from one of the abovementioned cancer types between 2009 and 2015. Differences in care by type of cancer were analyzed using multilevel analyses to control for clustering within general practices.

Results

Among all cancer types, patients with prostate cancer most often and patients with pancreatic cancer least often had a palliative treatment aim a month before death (95% resp. 84%). Prostate cancer patients were also least often admitted to hospital in the last month of life (18.5%) and least often died there (3.1%), whereas lung cancer patients were at the other end of the spectrum with 41.8% of them being admitted to hospital and 22.6% dying in hospital. Having a palliative treatment aim and being older were significantly associated with less hospital admissions, and having a palliative treatment aim, having prostate cancer, and dying in a more recent year were significantly associated with less hospital deaths.

Conclusion

There is large variation between patients with different cancer types with regard to treatment aims, hospital admissions, and hospital deaths. The results highlight the need for early initiation of GP palliative care to support patients from all cancer types to stay at the place they prefer as long as possible.

Estimating the need for palliative care at the population level: A cross-national study in 12 countries

BACKGROUND

To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed.

AIM

To estimate the proportion of decedents potentially in need of palliative care across 12 European and non-European countries.

DESIGN

This is a cross-sectional study using death certificate data.

SETTING/PARTICIPANTS

All adults (⩾18 years) who died in 2008 in Belgium, Czech Republic, France, Hungary, Italy, Spain (Andalusia, 2010), Sweden, Canada, the United States (2007), Korea, Mexico, and New Zealand ( N = 4,908,114). Underlying causes of death were used to apply three estimation methods developed by Rosenwax et al., the French National Observatory on End-of-Life Care, and Murtagh et al., respectively.

RESULTS

The proportion of individuals who died from diseases that indicate palliative care needs at the end of life ranged from 38% to 74%. We found important cross-country variation: the population potentially in need of palliative care was lower in Mexico (24%-58%) than in the United States (41%-76%) and varied from 31%-83% in Hungary to 42%-79% in Spain. Irrespective of the estimation methods, female sex and higher age were independently associated with the likelihood of being in need of palliative care near the end of life. Home and nursing home were the two places of deaths with the highest prevalence of palliative care needs.

CONCLUSION

These estimations of the size of the population potentially in need of palliative care provide robust indications of the challenge countries are facing if they want to seriously address palliative care needs at the population level.

Physicians' identification of the need for palliative care in people with intellectual disabilities

BACKGROUND

A growing number of people with intellectual disabilities (ID) is suffering from life-threatening chronic illnesses and is therefore in need for palliative care.

AIMS

We aimed to explore how the need for palliative care is recognized in people with ID.

METHODS AND PROCEDURES

We conducted a semi-structured interview study among 10 ID-physicians in the Netherlands.

OUTCOMES AND RESULTS

Identification of people with ID in need for palliative care mostly results from a process in which multiple signals from different information sources converge and lead to a growing awareness. As a result, ID-physicians do not expect people to return to their prior level of health or functioning, but rather expect an irreversible decline leading to death. The presence, stage and prognosis of the disease, physician-patient interaction, and communication with proxies who provide contextual information are factors influencing the process.

CONCLUSIONS AND IMPLICATIONS

Distinctive for a population of people with ID are the frequent diagnostic uncertainty in people with ID, the patients' communicational abilities and the reliance of ID-physicians on close proxies. We argue for a proactive attitude of physicians regarding care and support of people with ID with palliative care needs.

Caring for People with Diabetes at the End of Life

End-of-life care planning is assuming global significance. While general end-of-life care guidelines apply to diabetes, there are some diabetes-specific issues that need to be considered. These include the usual long trajectory to end-of-life care that enables clinicians and people with diabetes to proactively discuss when to change the focus of care from preventing diabetes complications (tight control) to a palliative approach. Palliative care aims to promote comfort and quality of life and reduce the unnecessary burden of care on individuals and their families. The aim of this paper is to discuss common disease trajectories and their relationship to diabetes care, outline strategies for proactively discussing these issues and suggest indications that palliative care is warranted.

Oncology healthcare professionals’ perspectives on the psychosocial support needs of cancer patients during oncology treatment

This study explored oncology healthcare professionals’ perspectives on the psychosocial support needs of diverse cancer patients during oncology treatment. Six themes were identified using thematic analysis. Healthcare professionals highlighted the importance of their sensitivity, respect and emotional tact during appointments in order to effectively identify and meet the needs of oncology patients. Participants also emphasised the importance of building rapport that recognises patients as people. Patients’ acceptance of treatment-related distress and uncertainty was described as required for uptake of available psychosocial supportive services. We offer some practical implications that may help improve cancer patients’ experiences during oncology treatment.

Integrating palliative care with usual care of diabetic foot wounds

Palliative care is a philosophy and a system for deciding care and can be used alone or integrated with usual chronic disease care. Palliative care encompasses end-of-life care. Palliative care aims to enhance quality of life, optimize function and manage symptoms including early in the course of chronic diseases. The purposes of this article are to outline palliative care and discuss how it can be integrated with usual care of diabetic foot wounds. Many people with diabetes who have foot wounds also have other comorbidities and diabetes complications such as cardiovascular and renal disease and depression, which affect medicine and other treatment choices, functional status, surgical risk and quality of life. Two broad of diabetic foot disease exist: those likely to heal but who could still benefit from integrated palliative care such as managing pain and those where healing is unlikely where palliation can be the primary focus. People with diabetes can die suddenly, although the life course is usually long with periods of stable and unstable disease. Many health professionals are reluctant to discuss palliative care or suggest people to document their end-of-life care preferences. If such preferences are not documented, the person might not achieve their desired death or place of death and health professionals and families can be confronted with difficult decisions. Palliative care can be integrated with usual foot care and is associated with improved function, better quality of life and greater patient and family satisfaction.

How could hospitalisations at the end of life have been avoided? A qualitative retrospective study of the perspectives of general practitioners, nurses and family carers

Background

Although many patients prefer to stay and die at home at the end of life, many are hospitalised. Little is known about how to avoid hospitalisations for patients living at home.

Aim

To describe how hospitalisation at the end of life can be avoided, from the perspective of the GPs, nurses and family carers.

Method

A qualitative design with face-to-face interviews was used. Taking 30 cases of patients who died non-suddenly, 26 GPs, 15 nurses and 18 family carers were interviewed in depth. Of the 30 patients, 20 were hospitalised and 10 were not hospitalised in the last three months of life.

Results

Five key themes that could help avoid hospitalisation at the end of life emerged from the interviews. The key themes were: 1) marking the approach of death, and shifting the mindset; 2) being able to provide acute treatment and care at home; 3) anticipatory discussions and interventions to deal with expected severe problems; 4) guiding and monitoring the patient and family in a holistic way through the illness trajectory; 5) continuity of treatment and care at home. If these five key themes are adopted in an interrelated way, this could help avoid hospitalisations, according to GPs, nurses and family carers.

Conclusions

The five key themes described in this study can be seen as strategies that could help in avoiding hospitalisation at the end of life. It is recommended that for all patients residing at home, GPs and community nurses work together as a team from the moment that it is marked that death is approaching up to the end of life.

Palliative care case managers in primary care: a descriptive study of referrals in relation to treatment aims

BACKGROUND

Three important elements of the World Health Organization (WHO) definition of palliative care are: 1) it includes patients who may have cure or life prolongation as treatment aims besides palliative care; 2) it is not exclusively for cancer patients; and 3) it includes attention to the medical, psychological, social, and spiritual needs of the patients and their families. Case managers (nurses with expertise in palliative care) may assist generalist primary care providers in delivery of good palliative care.

OBJECTIVES

This study investigates the referral of patients to case managers in primary care with regard to the three elements mentioned: diagnosis, treatment aims, and needs as reflected in reasons given for referral.

METHODS

In this cross-sectional survey in primary care among case managers and referrers to case management, case managers completed questionnaires for 687 patients; referrers completed 448 (65%).

RESULTS

Most patients referred have a combination of treatment aims (69%). Life expectancy and functional status of patients are lower for those with a treatment aim of palliation. Almost all (96%) of those referred are cancer patients. A need for psychosocial support is frequently given as a reason for referral (66%) regardless of treatment aim.

CONCLUSIONS

Referrals to case managers reflect two of three elements of the WHO definition. Mainly, patients are referred for support complementary to medical care, and relatively early in their disease trajectory. However, most of those referred are cancer patients. Thus, to fully reflect the definition, broadening the scope to reach other patient groups is important.

End-of-life care in general practice: A cross-sectional, retrospective survey of 'cancer', 'organ failure' and 'old-age/dementia' patients

BACKGROUND

End-of-life care is often provided in primary care settings.

AIM

To describe and compare general-practitioner end-of-life care for Dutch patients who died from 'cancer', 'organ failure' and 'old-age or dementia'.

DESIGN

A cross-sectional, retrospective survey was conducted within a sentinel network of general practitioners. General practitioners recorded the end-of-life care of all patients who died (1 January 2009 to 31 December 2011). Differences in care between patient groups were analysed using multivariate logistic regressions performed with generalised linear mixed models.

SETTING/PARTICIPANTS

Up to 63 general practitioners, covering 0.8% of the population, recorded the care of 1491 patients.

RESULTS

General practitioners personally provided palliative care for 75% of cancer, 38% of organ failure and 64% of old-age/dementia patients (adjusted odds ratio (confidence interval): cancer (reference category); organ failure: 0.28 (0.17, 0.47); old-age/dementia: 0.31 (0.15, 0.63)). In the week before death, 89% of cancer, 77% of organ failure and 86% of old-age/dementia patients received palliative treatments: (adjusted odds ratio (confidence interval): cancer (reference category); old-age/dementia: 0.54 (0.29, 1.00); organ failure: 0.38 (0.16, 0.92)). Options for palliative care were discussed with 81% of cancer, 44% of organ failure and 39% of old-age/dementia patients (adjusted odds ratio (confidence interval): cancer (reference category); old-age/dementia: 0.34 (0.21, 0.57); organ failure: 0.17 (0.08, 0.36)).

CONCLUSION

The results highlight the need to integrate palliative care with optimal disease management in primary practice and to initiate advance care planning early in the chronic disease trajectory to enable all patients to live as well as possible with progressive illness and die with dignity and comfort.

General practitioners' perspectives on the avoidability of hospitalizations at the end of life: A mixed-method study

BACKGROUND

Many patients are hospitalized in the last months of life. Little is known about the avoidability of these hospitalizations.

AIM

To explore whether and how hospitalizations could have been avoided in the last 3 months of life and barriers to avoid this, according to general practitioners in the Netherlands.

DESIGN

Sequential mixed-method design, starting with a cross-sectional nationwide questionnaire study among general practitioners, followed by in-depth interviews.

SETTING/PARTICIPANTS

General practitioners were asked about their most recent patient who died non-suddenly and who was hospitalized in the last 3 months of life. Additionally, 18 of these general practitioners were interviewed in depth about the situation surrounding hospitalization.

RESULTS

According to 24% of 319 general practitioners, the last hospitalization in the final 3 months of their patient's life could have been avoided. Of all avoidable hospitalizations, 46% could have been avoided by proactive communication with the patient, 36% by more communication between professionals around hospitalization, 28% by additional care and treatment at home, and 10% by patient and family support. In the in-depth interviews, general practitioners confirmed the aforementioned strategies, but also mentioned various barriers in daily practice, such as the timing of proactive communication with the patient, incompleteness of information transfer in acute situations, and the lack of awareness among patients and family that death was near.

CONCLUSION

A proactive approach could avoid some of the hospitalizations at the end of life, in the opinion of general practitioners. More insight is needed into communication and psychological barriers for timely discussions about end-of-life issues.

Early identification of palliative care needs by family physicians: A qualitative study of barriers and facilitators from the perspective of family physicians, community nurses, and patients

BACKGROUND

There is a growing recognition that a palliative care approach should be initiated early and not just in the terminal phase for patients with life-limiting diseases. Family physicians then play a central role in identifying and managing palliative care needs, but appear to not identify them accurately or in a timely manner.

AIM

To explore the barriers to and facilitators of the early identification by family physicians of the palliative care needs.

DESIGN, SETTING, AND PARTICIPANTS

Six focus groups (four with family physicians, n = 20, and two with community nurses, n = 12) and 18 interviews with patients with cancer, chronic obstructive pulmonary disease, heart failure, and dementia were held. Thematic analysis was used to derive themes that covered barriers and facilitators.

RESULTS

Key barriers and facilitators found relate to communication styles, the perceived role of a family physician, and continuity of care. Family physicians do not systematically assess non-acute care needs, and patients do not mention them or try to mask them from the family physician. This is embedded within a predominant perception among patients, nurses, and family physicians of the family physician as the person to appeal to in acute and standard follow-up situations rather than for palliative care needs. Family physicians also seemed to pay more often attention to palliative care needs of patients in a terminal phase.

CONCLUSION

The current practice of palliative care in Belgium is far from the presently considered ideal palliative care approaches. Facilitators such as proactive communication and communication tools could contribute to the development of guidelines for family physicians and policymakers in primary care.

Association between unmet needs and quality of life in hospitalised cancer patients no longer receiving anti-cancer treatment

Assessing the quality of life and unmet needs of cancer patients is an integral part of palliative care. This cross-sectional study sought to determine whether there is an association between quality of life and unmet needs, anxiety and depression in cancer patients who are no longer receiving anti-cancer treatment. The sample consisted of 93 patients from the oncology department at the University Hospital in Ostrava for whom further cancer treatment had been terminated as ineffective in halting the progression of their cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Patient Needs Assessment in Palliative Care (PNAP) questionnaire, and the Hospital Anxiety and Depression Scale (HADS) were used to collect data. The overall quality of life score was quite low at 46. Most unmet needs were defined in terms of physical, psychological or spiritual needs. Correlations were found between impaired quality of life and lower Karnofsky scores (r = 0.50); increased physical (r = 0.52), psychological (r = 0.44) and spiritual (r = 0.36) needs; and higher levels of anxiety (r = -0.30) and depression (r = -0.68). Effective management of patients' physical (pain, fatigue and depression), psychological and spiritual needs may improve their quality of life.

Reasons for hospitalisation at the end of life: differences between cancer and non-cancer patients

PURPOSE

Many patients are hospitalised during the final phase of life, even though most prefer to receive care at home until the end. This study aimed to explore the reasons and characteristics of hospitalisation in the final 3 months of life for patients who died non-suddenly, with a comparison between cancer patients and non-cancer patients.

METHODS

This study used a nationwide retrospective cross-sectional survey among Dutch general practitioners.

RESULTS

Of the 317 hospitalised patients, 65 % had cancer. Most common reasons for hospitalisation in the final 3 months of life were respiratory symptoms (31 %), digestive symptoms (17 %), and cardiovascular symptoms (17 %). Seventy-three percent of patients experienced an acute episode before hospitalisation, and for 46 % of patients, their own GP initiated the hospitalisation. Compared to non-cancer patients, cancer patients were significantly more likely to be aged less than 80 (81 versus 46 %), were more likely to be hospitalised because of digestive symptoms (22 versus 7 %), were less likely to have a curative treatment goal before the last hospitalisation (6 versus 22 %) and were less likely to die in hospital (22 versus 49 %).

CONCLUSIONS

Respiratory problems were the most common reasons for hospitalisation in the group of patients as a whole. Digestive problems were a frequent reason for hospitalisation in cancer patients and cardiovascular symptoms in non-cancer patients. Hospitalisation can therefore be anticipated by monitoring these relatively common symptoms. Also, timely communication with the patient is recommended about their preferences for hospital or home treatment in the case of an acute episode.