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Bilgin ES, Ülgüt R, Schneider N, Stiel S. Improving primary palliative care – a Delphi consensus study on measures for general practice in Germany. BMC PRIMARY CARE 2022; 23:12. [PMID: 35172733 PMCID: PMC8762944 DOI: 10.1186/s12875-021-01613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022]
Abstract
Abstract
Background
The majority of severely ill and dying people in Germany can be administered primary palliative care (PPC) by general practitioners (GP). However, the current provision of PPC does not match the needs of the population. Although several public health strategies aim at strengthening the role of GPs in PPC provision, it remains challenging for GP teams to integrate PPC into their daily routines.
Aim
A Delphi study with GPs was conducted to achieve consensus on specific measures for improving the integration of PPC into everyday GP practice.
Methods
The study is part of the junior research project “Primary Palliative Care in General Practice” (ALLPRAX). After having developed, tested and evaluated 26 practical measures for GP practices to improve their PPC, a Delphi consensus study among GPs took place. In 2020, 569 GPs were asked to rate the relevance and feasibility of the measures on a 4-point Likert scale via an anonymous online questionnaire. Consensus was defined as a sum percentage of ‘strongly agree’ and ‘somewhat agree’ responses ≥75% after two rounds. Between these rounds, measures that were not consented in the first round were adapted in light of respondents’ free text comments and suggestions.
Results
The response rate was 11.3% in round 1 (n = 64) and 53.1% in round 2 (n = 34). From the initial n = 26 measures, n = 20 measures achieved consensus and were included in the final intervention package. The consented measures pertained to four main topics: advance care planning with patients, consulting and informing patients and family caregivers, GP office organisation and continuing education. N = 6 measures did not achieve consensus, predominantly due to time and workload constraints.
Conclusion
The consented measures provide valuable support to improve the provision of PPC by GPs. They can be used freely and flexibly, according to the needs of individual GP teams, and are thus suitable for implementation nationwide.
Trial registration
The study was registered in the German Clinical Trials Register (Registration N° DRKS00011821; 4 December 2017; https://apps.who.int/trialsearch/) and the German Register of Health Care Research (Registration N° VfD_ALLPRAX_16_003817; 30 March 2017).
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Calton BA, Saks N, Reid T, Shepard-Lopez N, Sumser B. An Interprofessional Primary Palliative Care Curriculum for Health Care Trainees and Practicing Clinicians. Palliat Med Rep 2022; 3:80-86. [PMID: 35733444 PMCID: PMC9153988 DOI: 10.1089/pmr.2021.0074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brook A. Calton
- Division of Palliative Medicine and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, California, USA
| | - Naomi Saks
- Division of Palliative Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, California, USA
| | - Thomas Reid
- Division of Palliative Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, California, USA
| | - Nancy Shepard-Lopez
- Division of Palliative Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, California, USA
| | - Bridget Sumser
- Division of Palliative Medicine, Department of Medicine, The University of California, San Francisco, San Francisco, California, USA
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[Assessment tools for palliative care needs in patients with heart failure in general practice]. Wien Med Wochenschr 2021; 172:167-171. [PMID: 34648108 DOI: 10.1007/s10354-021-00890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Palliative care of patients with non-oncological, chronic diseases is for the most part achieved by general practicioners (GP). Currently however standardized questionnaires are barely used by GPs to determine the demand. It is far more an intuitive, individual decision, at what time and to what extend a palliative treatment takes place at home. Based on an example of a patient with chronic heart failure, it's determined, if and with which assessment-tools the need for a (specialised) palliative care in general medicine can be detected.
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Zimansky M, Hofmann B, Schneider N, Stiel S. [Implications for health services research in GP practices using the example of an intervention study on palliative care]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2021; 164:44-50. [PMID: 34215530 DOI: 10.1016/j.zefq.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION So far there has been little evidence of the extent to which project steps can affect the timing and successful implementation of research projects in general practitioner (GP) practices. Using the example of an intervention study on palliative care, the aim of this article is to report a) how the overall course of the project turned out compared to the original planning, and b) what recommendations can be derived to promote efficient implementation of intervention studies in GP practices. METHODS In two workshops each, GP practice teams selected specific measures to improve their palliative care and tested them during a four-month implementation phase. In order to track the progress of the project, the times at which the practice teams reported their participation in the study, the individual project steps and the contacts were documented and descriptively analysed using Microsoft Excel. RESULTS Due to a high willingness of practice teams to participate in the intervention study, recruitment was completed on time. The overall duration of the project was extended due to an increased workload for the preparation of an unexpectedly high number of selected measures to improve palliative care. DISCUSSION Conducting intervention studies in GP practices is promising if practice teams take an active and co-determining role during the entire research process. Research projects can best be implemented if they involve minimal time commitment for the practice teams, and if continuous personal support from the study team is ensured. CONCLUSION When planning future intervention studies with a high participatory share of GP practice teams, it is advisable to take into account potential additional work for the preparation and further development of intervention measures.
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Affiliation(s)
- Manuel Zimansky
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Birte Hofmann
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Nils Schneider
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stephanie Stiel
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland.
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Zimansky M, Gerdes A, Schneider N, Stiel S. Maßnahmen zur Verbesserung der allgemeinen ambulanten Palliativversorgung aus Sicht hausärztlicher Praxisteams. ZEITSCHRIFT FUR PALLIATIVMEDIZIN 2020. [DOI: 10.1055/a-1310-6865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Zusammenfassung
Hintergrund Zur Stärkung von AAPV fehlt es oftmals an Konkretisierung der Handlungsfelder für hausärztliche Praxisteams. Im Projekt „ALLPRAX“ wurde der Frage nachgegangen, welche Maßnahmen aus Sicht von Hausärzten und Medizinischen Fachangestellten das Potenzial haben, die AAPV in ihren jeweiligen Praxen zu verbessern.
Methode Acht Praxisteams wählten in jeweils einem Workshop anhand eines in einer vorherigen Projektphase entwickelten Maßnahmenkatalogs, geeignete Maßnahmen für eine Erprobung und Weiterentwicklung in ihrer eigenen Praxis aus.
Ergebnisse Die Praxisteams erachteten 35 aus 120 Maßnahmen für geeignet, die Palliativversorgung in ihrem Zuständigkeitsbereich zu verbessern. Am häufigsten wurden Maßnahmen zur vorausschauenden Versorgung von Patienten, Patienten- und Angehörigen-Beratung sowie Bildungsmaßnahmen für die Praxisteams ausgewählt.
Schlussfolgerung Zur Weiterentwicklung von AAPV in Hausarztpraxen bedarf es eines umfangreichen und zugleich differenzierten Interventionspakets.
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Affiliation(s)
- Manuel Zimansky
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
| | - Amrei Gerdes
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
| | - Nils Schneider
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
| | - Stephanie Stiel
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
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Stiel S, Ewertowski H, Krause O, Schneider N. What do positive and negative experiences of patients, relatives, general practitioners, medical assistants, and nurses tell us about barriers and supporting factors in outpatient palliative care? A critical incident interview study. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc08. [PMID: 33214790 PMCID: PMC7656812 DOI: 10.3205/000284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 05/06/2020] [Indexed: 11/30/2022]
Abstract
Background: The strengthening of the general practitioners’ (GPs’) role in palliative care (PC) has been identified as a top priority in order to improve PC in Germany. This study aims at exploring positive and negative experiences in PC in Germany from the perspectives of patients, relatives, and health care professionals in a primary care setting. Methods: Between March 2017 and August 2017, a total of 16 interviews with patients, relatives, GPs, medical assistants, and nurses were conducted. The Critical Incident Technique (CIT) was used to explore factors that influence excellent versus undesirable events in PC provision. Two researchers independently defined and counted critical incidents (CIs) from interview transcripts, performed a thematic analysis, and clustered the CIs into dimensions. Results: In summary, 16 interviews contained 280 CIs, divided into 130 positive and 150 negative CIs. The thematic analysis resulted in seven content domains, with each including positive and negative CIs, respectively: 1) way of care provision, 2) availability of care providers, structures, medication, and aids, 3) general formal conditions of care provision, 4) bureaucracy, 5) working practices in health care teams, 6) quality and outcome of care provision, and 7) communication. Conclusions: The results raise awareness for the aspects that lead to successful or undesirable PC experiences, observed from different perspectives. They open up the potential for primary PC improvement. Future research will facilitate development and implementation of more tailored interventions in order to improve generalists’ PC.
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Affiliation(s)
- Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Helen Ewertowski
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Olaf Krause
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Hannover, Germany
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Stiel S, Krause O, Berndt CS, Ewertowski H, Müller-Mundt G, Schneider N. Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care. Z Gerontol Geriatr 2019; 53:763-769. [PMID: 31828367 DOI: 10.1007/s00391-019-01668-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/22/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services. OBJECTIVE What are the challenges for GPs in caring for frail older patients at the end of their lives? MATERIAL AND METHODS A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory. RESULTS The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines. CONCLUSION In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.
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Affiliation(s)
- Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany.
| | - Olaf Krause
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Carolin Sophie Berndt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Helen Ewertowski
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
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Zens TJ, Kopecky KE, Schwarze ML, Suwanabol PA. Surgery Hurts: Characterizing the Experience of Pain in Surgical Patients as Witnessed by Medical Students. JOURNAL OF SURGICAL EDUCATION 2019; 76:1506-1515. [PMID: 31060970 DOI: 10.1016/j.jsurg.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/16/2019] [Accepted: 04/16/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The patient experience around surgical care is poorly characterized. Medical students have a unique position on the surgical team, which allows them to observe patient experiences that may otherwise be overlooked. The objective of this study was to characterize surgical patients' experience with pain as witnessed by medical students. STUDY DESIGN At the end of an 8-week surgical clerkship, we asked all third-year medical students to write a reflective essay describing one surgical patient in pain. We collected 341 essays over a 4-year period and used qualitative content analysis to explore the students' reports of pain experienced by surgical patients. RESULTS When asked to tell a story about a surgical patient in pain, medical students report vivid descriptions of physical agony, emotional distress, and patient regret. For example, "Throughout the procedure our patient cried out and writhed in agony from the searing pain in his chest," and "The patient was practically shedding tears, complaining of pain, as [we] changed her dressing." The students' accounts reveal wide-ranging physical and emotional suffering among surgical patients, including alterations in self-image and feelings of vulnerability. Pain and suffering were intensified when patients felt they had lost control, in settings of uncertain prognosis and with unexpected outcomes. CONCLUSIONS Students' descriptions of the surgical patient's experience are disturbingly graphic. They expose suffering ranging from generalized discomfort to anguish and excruciating pain. These data suggest that surgical patients have substantial unmet needs with respect to symptom management and emotional support that, if better addressed, could improve the patient experience.
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Affiliation(s)
- Tiffany J Zens
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Kimberly E Kopecky
- Department of Surgery, Stanford University, Stanford, California; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin, Madison, Wisconsin; Department of Medical History and Bioethics, University of Wisconsin, Madison, Wisconsin
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Mühlensiepen F, von Peter S, Thoma S, Marschke J, Rozanski F, Neugebauer E, Heinze M. [Pilot Project: Reinforcement of Outpatient Palliative Care in the State of Brandenburg - An Analysis of Documentation Data of Primary Palliative Care]. DAS GESUNDHEITSWESEN 2019; 82:984-991. [PMID: 31426106 DOI: 10.1055/a-0905-2974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Quantitative data on primary palliative care (AAPV) in Germany is scarce. In order to reinforce outpatient palliative care, a pilot project was implemented and evaluated in 2 regions of Brandenburg. The aim of this study was to gain an insight into AAPV based on documentation data from the pilot project: How was AAPV realized in the pilot project? How does the implementation of AAPV differ in the 2 project regions? MATERIALS AND METHODS The study is based on retrospective analysis of the data on 108 patients documented by 13 physicians in 2 regions of Brandenburg using PalliDoc® software. The results were analysed by descriptive statistical methods. RESULTS Each participating doctor documented the care process of 7.7 patients on average during the observation period. Overall, about 66% of the patients were diagnosed with a tumour as the main diagnosis. The average duration of care for patients in the pilot project was 171.3 days. On average, doctors documented 9.1 contacts per patient with contacts lasting 20:28 min. The average route to the patient was 9.3 kilometres. CONCLUSIONS Our results indicate that the execution of AAPV is highly dependent on regional circumstances as well as on the existing offers and services of hospice and palliative care. Compared to data from the evaluation of palliative care teams in other German regions, it appears that the care processes in AAPV last longer and a larger number of patients without underlying oncological disease has been treated under AAPV than in specialized palliative care.
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Affiliation(s)
- Felix Mühlensiepen
- KV Consult- und Managementgesellschaft mbH, Potsdam.,Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Sebastian von Peter
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin.,Hochschulklinik für Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf
| | - Samuel Thoma
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin.,Hochschulklinik für Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf
| | | | | | - Edmund Neugebauer
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Martin Heinze
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin.,Hochschulklinik für Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf
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Forbat L, Johnston N, Mitchell I. Defining 'specialist palliative care': findings from a Delphi study of clinicians. AUST HEALTH REV 2019; 44:313-321. [PMID: 31248475 DOI: 10.1071/ah18198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/20/2019] [Indexed: 11/23/2022]
Abstract
Objective This study aimed to achieve consensus regarding what distinguishes specialist from non-specialist palliative care to inform service organisation and delivery to patients with life-limiting conditions. Methods A three-phase Delphi study was undertaken, involving qualitative interviews and two questionnaire cycles. Thirty-one clinicians (nurses, doctors and social workers) working with a wide range of patients participated in interviews, of whom 27 completed two questionnaire cycles. Results Consensus was gained on 75 items that define specialist palliative care and distinguish it from non-specialist palliative care. Consensus was gained that specialist palliative care clinicians have advanced knowledge of identifying dying, skills to assess and manage complex symptoms to improve quality of life, have advanced communication skills and perform distinct clinical practices (e.g. working with the whole family as the unit of care and providing support in complex bereavement). Non-specialist palliative care involves discussions around futile or burdensome treatments, and care for people who are dying. Conclusions Areas of connection were identified: clinicians from disease-specific specialties should be more involved in leading discussions on futile or burdensome treatment and providing care to people in their last months and days of life, in collaboration with specialists in palliative care when required. What is known about the topic? At present there is no evidence-based definition or agreement about what constitutes specialist palliative care (as opposed to palliative care delivered by non-specialists) in the Australian Capital Territory. An agreed definition is needed to effectively determine the workforce required and its clinical skill mix, and to clarify roles and expectations to mitigate risks in not adequately providing services to patients with life-limiting conditions. What does this paper add? This paper offers, for the first time, an evidence-based definition that distinguishes specialist palliative care from non-specialist palliative care. End of life care and bereavement support are not just the remit of specialist palliative care clinicians. Clinicians from beyond specialist palliative care should lead discussions about futile or burdensome treatment. What are the implications for practitioners? The findings of this study can facilitate implementation of palliative care strategies by enabling practitioners and patients to distinguish who should be delivering what care.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, FK9 4LA, UK; and Faculty of Health Sciences, Australian Catholic University, Canberra, ACT 2600, Australia; and Corresponding author.
| | | | - Imogen Mitchell
- Medical School, Australian National University, Florey Building, 54 Mills Road, Canberra, ACT 2601, Australia. ; and Canberra Hospital, Building 4, Level 2, Garran, ACT 2605, Australia
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[The role of the family doctor in the palliative care of chronic and terminally ill patients]. Semergen 2019; 45:349-355. [PMID: 30718073 DOI: 10.1016/j.semerg.2018.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/28/2018] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
Abstract
The objective of this work was to identify the role of family physicians in the care of patients and their families in the approach to the end of life. Nowadays, with the increase in the demand for care of patients with terminal illnesses, there is also evidence on the lack of physicians with the profile and skills to fulfil this coverage deficit. A review of the literature was carried out in five databases from January 2015 to May 2018, and concluded that family doctors, based on their professional skills, ability to engage with the patients, their families, and their performance in the coordination of medical resources, are in an ideal position to attend and solve complex problems of patients at the end of life. In the present review, the specific roles of family physicians in clinical and psychosocial areas, and also the difficulties in facing the challenges in the care of patients and families undergoing the end of life process are described.
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