General practice vocational training in the UK: what teaching is given in palliative care?

Palliative Care Training: A Survey of Physicians in Australia and Europe

The purpose of this paper is to present data about the level and background characteristics of physicians’ training in palliative care in Australia (AU), Belgium (BE), Denmark (DK), Italy (IT), the Netherlands (NL), Sweden (SE) and Switzerland (CH) (n=16,486). The response rate to an anonymous questionnaire differed between countries (39%-68%). In most countries approximately half of all responding physicians had any formal training in palliative care (median: 3–10 days). Exceptions were NL (78%) and IT (35%). The most common type of training was a postgraduate course. Physicians in nursing home medicine (only in NL), geriatrics, oncology (not in NL), and general practice had the most training. In all seven countries, physicians with such training discussed options for palliative care and options to forgo life-sustaining treatment more often with their patients than did physicians without. Irrespective of earlier palliative care training, 87%-98% of the physicians wanted extended training.

Primary care physicians' educational needs and learning preferences in end of life care: A focus group study in the UK

BACKGROUND

Primary care physicians (General Practitioners (GPs)) play a pivotal role in providing end of life care (EoLC). However, many lack confidence in this area, and the quality of EoLC by GPs can be problematic. Evidence regarding educational needs, learning preferences and the acceptability of evaluation methods is needed to inform the development and testing of EoLC education. This study therefore aimed to explore GPs' EoLC educational needs and preferences for learning and evaluation.

METHODS

A qualitative focus group study was conducted with qualified GPs and GP trainees in the UK. Audio recordings were transcribed and analysed thematically. Expert review of the coding frame and dual coding of transcripts maximised rigour.

RESULTS

Twenty-eight GPs (10 fully qualified, 18 trainees) participated in five focus groups. Four major themes emerged: (1) why education is needed, (2) perceived educational needs, (3) learning preferences, and (4) evaluation preferences. EoLC was perceived as emotionally and clinically challenging. Educational needs included: identifying patients for palliative care; responsibilities and teamwork; out-of-hours care; having difficult conversations; symptom management; non-malignant conditions; and paediatric palliative care. Participants preferred learning through experience, working alongside specialist palliative care staff, and discussion of real cases, to didactic methods and e-learning. 360° appraisals and behavioural assessment using videoing or simulated interactions were considered problematic. Self-assessment questionnaires and patient and family outcome measures were acceptable, if used and interpreted correctly.

CONCLUSIONS

GPs require education and support in EoLC, particularly the management of complex clinical care and counselling. GPs value mentoring, peer-support, and experiential learning alongside EoLC specialists over formal training.

Recording patient preferences for end-of-life care as an incentivized quality indicator: what do general practice staff think?

INTRODUCTION

Since April 2009, indicators for the UK Quality and Outcomes Framework pilot have been developed and piloted across a nationally representative sample of practices. In October 2009 a single palliative care indicator was piloted for 6 months that looked at, 'the percentage of patients on the palliative care register who have a preferred place to receive end-of-life care documented in the records'.

AIM

The aim of this study was to gain the views and experiences of general practice staff on whether the inclusion of a single incentivized indicator to record the preferred place to receive end-of-life care would improve the quality of palliative care. Any issues arising from its implementation in a pay-for-performance scheme were also explored.

METHODS

Interviews took place with 57 members of staff in 24 practices: 21 GPs, 16 practice managers, 12 nurses and eight others (mostly information technology experts).

RESULTS

The indicator was not deemed appropriate for incentivization due to concerns about incentivizing an isolated, single issue within a multi-faceted, multi-disciplinary and complex topic. Palliative care was seen to be too sensitive and patient specific to be amenable to population-level quality measurement. In implementation, the indicator would pose potential harm to patients who may be asked about their end-of-life care at an inappropriate time and by a member of staff who may not be best placed to address this sensitive topic.

CONCLUSIONS

The most appropriate time to ask a patient about end-of-life care is subjective and patient specific and therefore does not lend itself to an inflexible single indicator. Focusing on one isolated question simplifies and distracts from a multi-faceted and complex issue and may lead to patient harm.

Exploring preferences for place of death with terminally ill patients: qualitative study of experiences of general practitioners and community nurses in England

OBJECTIVE

To explore the experiences and perceptions of general practitioners and community nurses in discussing preferences for place of death with terminally ill patients.

DESIGN

Qualitative study using semistructured interviews and thematic analysis.

PARTICIPANTS

17 general practitioners and 19 nurses (16 district nurses, three clinical nurse specialists).

SETTING

15 general practices participating in the Gold Standards Framework for palliative care from three areas in central England with differing socio-geography. Practices were selected on the basis of size and level of adoption of the standards framework.

RESULTS

All interviewees bar one had experience of discussing preferred place of death with terminally ill patients. They reported that preferences for place of death frequently changed over time and were often ill defined or poorly formed in patients' minds. Preferences were often described as being co-created in discussion with the patient or, conversely, inferred by the health professional without direct questioning or receiving a definitive answer from the patient. This inherent uncertainty challenged the practicability, usefulness, and value of recording a definitive preference. The extent to which the assessment of enabling such preferences can be used as a proxy for the effectiveness of palliative care delivery is also limited by this uncertainty. Generally, interviewees did not find discussing preferred place of death an easy area of practice, unless the patient broached the subject or led the discussions.

CONCLUSIONS

Further research is needed to enable development of appropriate training and support for primary care professionals. Better understanding of the importance of place of death to patients and their carers is also needed.

General practitioners' attitudes to palliative care: A Western Australian rural perspective

BACKGROUND

People with a terminal illness and their families who live in rural or remote areas of Australia face difficulties in accessing palliative care services as a result of physical isolation. This leads to rural general practitioners (GPs) carrying the burden of care, which is often exacerbated by a lack of support staff.

OBJECTIVE

This research addressed the following questions: What are GPs' attitudes to palliative care in a rural center of Western Australia? What factors contribute to GPs' attitudes to palliative care in a rural center of Western Australia? What are the perceived barriers to the provision of palliative care in a rural center of Western Australia?

DESIGN

A qualitative in-depth research design was used for this study due to the exploratory nature of the research. A model of attitudes that considers an attitude as a summary evaluation of an issue based on: cognitive information, (thoughts and beliefs), affective or emotional information, and information concerning behavior, was used.

PARTICIPANTS

Participants were 10 registered GPs located within the Greater Bunbury Division of General Practice in Western Australia.

RESULTS

Six themes emerged from the research: maintaining patients' quality of life, providing continuity of care, experiencing emotional issues, collaborating with a multidisciplinary team, acknowledging the need for education and training, and dealing with the wider context.

CONCLUSION

Education and training for rural GPs needs to be relevant to the local context and needs to focus on emotions and beliefs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Doctors' understanding of palliative care

Palliative care has been challenged to share its message with a wider audience, and for many years it has been articulating an approach that is suitable for all patients. However, it is not clear how widely this message has been accepted. As part of a study into end-of-life care for heart failure, we conducted seven focus groups with doctors in general practice, palliative medicine, cardiology, geriatrics and general medicine. In these, we explored doctors' understanding of palliative care. Participants displayed a reasonable grasp of the wider concept of palliative care, but the specialists' role was ill-defined, reflected in scepticism about their place outside of cancer. Perceptions of palliative care fell into three broad areas: it was more than a service, about managing dying, and the concern of nurses, rather than doctors. Palliative care was welcomed as providing permission to fail, whilst representing a dilemma between quantity and quality of life for the interviewees. Our work suggests that specialist palliative care has been partially successful in getting their message across, and poor understanding or receptivity are not major barriers to implementing palliative care. Educational or other interventions to implement change in palliative care need to acknowledge the complex interaction of factors influencing physicians' behaviour.

A UK-wide postal survey to evaluate palliative care education amongst General Practice Registrars

OBJECTIVES

To evaluate the content of General Practice Registrars' (GPRs) palliative care education in the U.K.

METHODS

Postal questionnaires were sent to 492 eligible GPRs across six purposively sampled U.K. postgraduate deaneries.

RESULTS

GPRs were satisfied with their course coverage on control of pain, other symptoms and communication skills, and were also moderately confident in applying the knowledge gained in these areas. They showed a high level of knowledge in the management of cancer-related pain. There was less satisfaction with the coverage given to syringe driver use (38%) and bereavement care (36%), with fewer expressing confidence in applying their knowledge to these areas.

CONCLUSIONS

GPRs have mixed perceptions about their palliative care education. Future educational packages should ensure that GPRs receive planned systematic training in bereavement care and some practical experience in the use of syringe drivers. Both Postgraduate General Practice Education departments and specialist palliative care providers should explore ways of working more closely together to provide GPRs with more expertize in palliative care.