Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

Specialized expertise among healthcare professionals in palliative care - A scoping review

BACKGROUND

The generalist-plus-specialist palliative care model is endorsed worldwide. In the Netherlands, the competencies and profile of the generalist provider of palliative care has been described on all professional levels in nursing and medicine. However, there is no clear description of what specialized expertise in palliative care entails, whereas this is important in order for generalists to know who they can consult in complex palliative care situations and for timely referral of patients to palliative care specialists.

OBJECTIVE

To gain insight in the roles and competencies attributed to palliative care specialists as opposed to generalists.

METHODS

A scoping review was completed based on PRISMA-ScR guidelines to explore the international literature on the role and competence description of specialist and expert care professionals in palliative care. Databases Embase.com, Medline (Ovid), CINAHL (Ebsco) and Web of Science Core Collection were consulted. The thirty-nine included articles were independently screened, reviewed and charted. Thematic codes were attached based on two main outcomes roles and competencies.

RESULTS

Five roles were identified for the palliative care specialist: care provider, care consultant, educator, researcher and advocate. Leadership qualities are found to be pivotal for every role. The roles were further specified with competencies that emerged from the analysis. The title, roles and competencies attributed to the palliative care specialist can mostly be applied to both medical and nursing professionals.

DISCUSSION

The roles and competencies derived from this scoping review correspond well with the seven fields of competence for medical/nursing professionals in health care of the CanMEDS guide. A specialist is not only distinguished from a generalist on patient-related care activities but also on an encompassing level. Clarity on what it entails to be a specialist is important for improving education and training for specialists.

CONCLUSION

This scoping review adds to our understanding of what roles and competencies define the palliative care specialist. This is important to strengthen the position of the specialist and their added value to generalists in a generalist-plus-specialist model.

A Case Management Approach in Stroke Care: A Mixed-Methods Acceptance Analysis From the Perspective of the Medical Profession

PURPOSE OF STUDY

In terms of continuous and coordinated health care, cross-sectoral care structures are crucial. However, the German health care system is characterized by fragmentation of medical services and responsibilities. This fragmentation leads to multiple interfaces frequently causing loss of information, effectiveness, and quality. The concept of case management has the potential to improve cooperation between sectors and health care providers. Hence, a case management intervention for patients with stroke was evaluated with an acceptance analysis on the physicians' willingness to cooperate with stroke managers and their assessment of the potential of case management for the health care of patients with stroke.

PRIMARY PRACTICE SETTINGS

Primary practice settings included physicians working in the hospital, rehabilitation, and outpatient sectors who had actual or potential contact with a stroke case manager within the project region of East Westphalia-Lippe.

METHODOLOGY AND SAMPLE

The analysis was conducted using a mixed-methods approach. Expert interviews were conducted in 2020. Afterward a questionnaire was developed, which was then distributed to physicians in 2021. Both the interviews and the questionnaire included questions on conceptual knowledge and concrete expectations prior of the project, on experiences during the project and on recommendations and physicians' assessment of future organization in health care to classify and describe the acceptance.

RESULTS

Nine interviews were conducted and 23 questionnaires were completed. Only slightly more than 50% of the physicians had prior knowledge of the case management approach. Overall, ambiguous results concerning the acceptance of case managers were revealed. Additional personal assistance for patients with stroke was seen as beneficial at the same time critical perspectives regarding further fragmentation of health care and overlapping of competences with existing professional groups or forms of health care were collected. General practitioners in particular were critical of the case management approach.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

From the physicians' point of view, at least two changes are necessary for the project approach to be integrated into standard care. First, the target group should be adapted according to the case management approach. Second, the delegation of tasks and responsibilities to case managers should be revised. The sectoral difference in the acceptance of case managers by physicians indicates that active cooperation and communication in everyday work has direct impact on the acceptance of a new occupational profession. Physician acceptance has a significant impact on the implementation of new treatment modalities and thus influences the overall quality of health care.

Are We Consulting, Sharing Care, or Taking Over? A Conceptual Framework

Background

Primary- and specialist-level palliative care services are needed. They should work collaboratively and synergistically. Although several service models have been described, these remain open to different interpretations and deployment.

Aim

This article describes a conceptual framework, the Consultation-Shared Care-Takeover (C-S-T) Framework, its evolution and its applications.

Design

An iterative process informed the development of the Framework. This included a symposium, literature searches, results from three studies, and real-life applications.

Results

The C-S-T Framework represents a spectrum anchored by the Consultation model at one end, the Takeover model at the other end, and the Shared Care model in the center. Indicators, divided into five domains, help differentiate one model from the other. The domains are (1) Scope (What aspects of care are addressed by the palliative care clinician?); (2) Prescriber (Who prescribes the treatments?); (3) Communication (What communication occurs between the palliative care clinician and the patient's attending clinician?); (4) Follow-up (Who provides the follow-up visits and what is their frequency?); and (5) Most responsible practitioner (MRP) (Who is identified as MRP?). Each model demonstrates strengths, limitations, uses, and roles.

Conclusions

The C-S-T Framework can be used to better describe, understand, assess, and monitor models being used by specialist palliative care teams in their interactions with primary care providers and other specialist services. Large studies are needed to test the application of the Framework on a broader scale in health care systems.

Cancer care and economic burden-A narrative review

Cancer care poses a significant economic burden in India, where noncommunicable diseases contribute to a large number of deaths and disability-adjusted life-years. Despite economic growth, equitable wealth distribution remains a challenge, leading to inequalities in healthcare access. India's healthcare system is primarily privatized, financed through out-of-pocket expenditure (OOPE), and lacks coverage for a majority of the population. As a result, individuals without financial means face catastrophic health consequences when seeking necessary healthcare. OOPE in India's healthcare system is a major concern, with medicines accounting for a significant portion of expenses, followed by diagnostic tests and consultation fees. Nonmedical expenses also contribute to the financial burden. Cancer care specifically faces substantial financial challenges, with high treatment costs, reduced workforce participation, and the need for distress financing. Cancer-related OOPE is predominantly borne by patients and their families, leading to significant financial strain. The lack of comprehensive health insurance coverage and limited access to publicly funded healthcare services exacerbate the problem. Catastrophic health expenditure (CHE) in cancer care is prevalent, pushing households into financial distress and potentially impoverishment. Efforts have been made to address this issue, such as increasing public spending on healthcare and implementing health insurance schemes. However, challenges remain in ensuring their effectiveness and reach. The role of family care physicians is crucial in supporting patients and their families during catastrophic health expenditures related to cancer-related palliative care. They coordinate care, provide advocacy, emotional support, symptom management, and facilitate end-of-life discussions. Comprehensive measures are needed to strengthen healthcare infrastructure, improve access to affordable cancer care, enhance health insurance coverage, and implement supportive measures for cancer patients. Additionally, promoting preventive measures and early detection can help reduce the need for expensive treatments and decrease the risk of catastrophic health expenditures.

Exploring the delivery of end-of-life care by community nurses

AIMS

To understand what aspects of care and support were important to bereaved relatives and to explore the experiences of nurses delivering end of life care.

METHODS

Interviews and focus groups were undertaken with 17 family members, 31 community nurses and 13 community hospital staff. A workshop was held with 6 family members, 13 community nurses and 3 hospital nurses to review findings and make recommendations for improvement.

FINDINGS

Four themes were identified: relationships and being treated as a whole person; being able to make choices; getting help when and where it is needed; specialist advice and care, especially at the very end of life.

CONCLUSION

Seeking feedback from relatives was valued both by family members and the staff and has provided an effective model to lead to focussed improvements.

Unrepresented, unheard and discriminated against: A qualitative exploration of relatives' and professionals' views of palliative care experiences of people of African and Caribbean descent during the COVID-19 pandemic

BACKGROUND

People of African and Caribbean descent experienced disproportionately high mortality from COVID-19 and have poor access to palliative care.

AIM

To explore palliative care experiences of people of African and Caribbean descent during and immediately prior to the pandemic.

DESIGN

Qualitative interview study with thematic analysis. Refinement of themes/recommendations in consultation with an expert patient and public advisory group.

SETTING/PARTICIPANTS

Twenty-six bereaved relatives and 13 health/social care professionals (cared for people of African and Caribbean descent) from throughout England, recruited using social media, community networks and direct advertising to over 150 organisations.

RESULTS

Three themes were identified: Representation: Participants did not see themselves reflected in the palliative care services and did not expect their needs to be understood. Mistrust of the healthcare system and perceptions of racism were common and led to anticipation of inequitable care. Personalisation: Relatives and professionals reported a lack of cultural and religious sensitivity in healthcare. Assumptions were made based on ethnicity, and services not offered to all. Awareness and education: Professionals felt they lacked the knowledge to provide care to diverse communities, but were reluctant to ask, due to fear of making mistakes. Inequitable access to services was exacerbated by, but not unique to, the pandemic. Participants recommended raising awareness of palliative services, building professional competence in culturally-sensitive care, and greater ethnic diversity within services.

CONCLUSIONS

Person-centred, culturally-competent palliative care is not the norm for people of African and Caribbean descent. Expectations of inequitable care are widespread. Sustained action on multiple fronts is needed.

Novel method for predicting nonvisible symptoms using machine learning in cancer palliative care

End-of-life patients with cancer may find expressing their symptoms difficult if they can no longer communicate verbally because of deteriorating health. In this study, we assessed these symptoms using machine learning, which has excellent predictive capabilities and has recently been applied in healthcare. We performed a retrospective clinical survey involving 213 patients with cancer from August 2015 to August 2016. We divided the reported symptoms into two groups-visible and nonvisible symptoms. We used decision tree analysis, an analytical machine learning method that organizes and analyzes information in the form of a tree diagram to visually represent the information structure. Our machine learning model used patient background data and visible symptoms to predict nonvisible symptoms: pain, dyspnea, fatigue, drowsiness, anxiety, delirium, inadequate informed consent, and spiritual issues. The highest and/or lowest values for prediction accuracy, sensitivity, and specificity were 88.0%/55.5%, 84.9%/3.3%, and 96.7%/24.1%, respectively. This work will facilitate better assessment and management of symptoms in patients with cancer. This study was the first to predict nonvisible symptoms using decision tree analyses for patients with cancer receiving palliative care. Notably, applications based on our results may assess symptoms to the same extent as healthcare professionals.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

The challenges for health professionals delivering palliative care in the community during the COVID-19 pandemic: An integrative review

Objectives

The growing demand for palliative care has been accelerated due to the COVID-19 pandemic. However, providing community-based palliative care was also more difficult to do safely and faced several challenges. The goal of this integrative review was to identify, describe, and synthesize previous studies on the challenges for health professionals delivering palliative care in the community during the COVID-19 pandemic.

Methods

Searches were carried out on the Ovid MEDLINE, CINAHL, PsycINFO, Social Care Online, PubMed, Embase, and Expanded Academic databases. Journals typically reporting palliative care and community health studies were also searched (Palliative Medicine, Journal of Pain and Symptom Management, and Health & Social Care in the Community). All articles were peer-reviewed and published in English between December 2019 and September 2022.

Results

Database and hand searches identified 1231 articles. After duplicates were removed and the exclusion criteria applied, 27 articles were included in the final review. Themes in the research findings centered on 6 interconnected categories. The challenges imposed by the pandemic (lack of resources, communication difficulties, access to education and training, and interprofessional coordination), as well as the varying levels of success of the health-care responses, impacted the well-being of health professionals and, in turn, the well-being and care of patients and families.

Significance of results

The pandemic has provided the impetus for rethinking flexible and innovative approaches to overcome the challenges of delivering community palliative care. However, existing governmental and organizational policies require revision to improve communication and effective interprofessional collaboration, and additional resources are needed. A blended model of virtual and in-person palliative care delivery may provide the best solution to community palliative care delivery moving forward.

Understanding and Balancing Generalist-Specialist Approaches in Dementia Research and Care Practice, Qualitative Research with 44 Dementia Professors in The Netherlands

Dementia is one of the leading causes of death and disability among citizens and a societal challenge because of aging worldwide. As dementia has physical, psychological, social, material, and economic impacts, both research and care practice require many disciplines to develop and implement diagnostics, medical and psychosocial interventions, and support, crossing all domains of housing, public services, care, and cure. Notwithstanding large research efforts, much knowledge about mechanisms, interventions, and needs' based care pathways is still lacking. To cope with these challenges in research and practice, this paper is the first to question how generalist and specialist orientations can be unfolded. In the Netherlands, all dementia professors (N = 44) at eight Dutch academic centers have been interviewed. Qualitative analyses revealed three subgroups of dementia professors, one with a generalist orientation, one adhering to specialist approaches, and a third group that pleas for mixed orientations, with some differences between research and care practice. Each group has arguments for its generalist/specialist vision, but the synthesis suggests a paradigm of personalized and integrated dementia care, aimed at the individual in his own living environment. Sustainable strategies to cope with dementia require (inter)national programs and strong collaboration to build multi- and interdisciplinarity within and between research and practice.

Role and response of primary healthcare services in community end-of-life care during COVID-19: Qualitative study and recommendations for primary palliative care delivery

BACKGROUND

The need for end-of-life care in the community increased significantly during the COVID-19 pandemic. Primary care services, including general practitioners and community nurses, had a critical role in providing such care, rapidly changing their working practices to meet demand. Little is known about primary care responses to a major change in place of care towards the end of life, or the implications for future end-of-life care services.

AIM

To gather general practitioner and community nurse perspectives on factors that facilitated community end-of-life care during the COVID-19 pandemic, and to use this to develop recommendations to improve future delivery of end-of-life care.

DESIGN

Qualitative interview study with thematic analysis, followed by refinement of themes and recommendations in consultation with an expert advisory group.

PARTICIPANTS

General practitioners (n = 8) and community nurses (n = 17) working in primary care in the UK.

RESULTS

General practitioner and community nurse perspectives on factors critical to sustaining community end-of-life care were identified under three themes: (1) partnership working is key, (2) care planning for end-of-life needs improvement, and (3) importance of the physical presence of primary care professionals. Drawing on participants' experiences and behaviour change theory, recommendations are proposed to improve end-of-life care in primary care.

CONCLUSIONS

To sustain and embed positive change, an increased policy focus on primary care in end-of-life care is required. Targeted interventions developed during COVID-19, including online team meetings and education, new prescribing systems and unified guidance, could increase capacity and capability of the primary care workforce to deliver community end-of-life care.

GPs’ involvement in specialised palliative home care: A mixed methods study in Germany

Background

General practitioners (GPs) are important providers of palliative home care (PHC). To deliver adequate palliative care, cooperation with specialised PHC teams is necessary. Specialised PHC is a type of care for severely ill patients by specialised providers. Little is known about the involvement of German GPs in specialised PHC.

Objectives

To analyse GPs’ experience with realised and desired involvement in specialised PHC. Realised involvement means GPs took part in specialised PHC patients’ care. Desired involvement is GPs’ hoped-for cooperation with specialised PHC teams: GPs could state whether they want to stay involved, be informed, or provide medical services themselves after referral to specialised PHC.

Methods

Mixed methods design (focus group with 6 GPs; survey of 445 GPs in North Rhine, Germany, about their experiences in PHC/specialised PHC): Qualitative data was interpreted using content analysis. The authors developed a questionnaire and performed descriptive analysis based on qualitative results.

Results

GPs are mostly satisfied with specialised PHC teams’ care, although they report cooperation is not always optimal. GPs describe a high satisfaction with quality of care by specialised PHC teams. However, physicians with higher PC knowledge are less satisfied with specialised PHC. Also, GPs are often less involved in specialised PHC than they wish, especially when they have a higher PC qualification.

Conclusion

In general, GPs are satisfied with the quality of care provided by specialised PHC teams but GPs do not always perceive cooperation as optimal. Involvement of GPs in specialised PHC needs to be improved.

A task service and a talking service: A qualitative exploration of bereaved family perceptions of community nursing care at the end of life

BACKGROUND

Greater emphasis on community-based care at the end of life is supported by the premise that most people want to be cared for and die at home. As such, it is important to understand the current state of palliative care nursing within an integrated generalist-specialist model of care in the community.

AIM

To explore bereaved family perceptions and experiences of community nursing at the end of life, with a particular focus on service integration.

DESIGN

A qualitative study design using semi-structured telephone interviews with bereaved family. A critical realist framework was used to inform the analysis of interview data and thematic analysis of data was used to identify key themes.

SETTING/PARTICIPANTS

Participants were the family carers of patients who had died within the catchment area of two large District Health Boards in Auckland, New Zealand.

RESULTS

Twenty-three participants were interviewed. Participants described their experiences of community nursing in terms of the service they provided. Hospice nursing roles were described in terms of a "talking service" and District Nursing as a "task service." There was minimal expectation of the general practice nurse in terms of palliative care support and little evidence of service integration.

CONCLUSION

Findings from this study support the need for a new integrated model of palliative care nursing which utilizes the unique skill set of nurses working across all community care settings including general practice, hospice and district nursing services. Accommodating different models of nursing care which can be responsive to patient need rather than limited to a defined service delivery model.

"People are more afraid of a dementia diagnosis than of death": The challenges of supporting advance care planning for persons with dementia in community settings

Improving early uptake of advance care planning (ACP) for persons with dementia and their families requires that staff in community-based settings feel armed and equipped to encourage and support this process. Yet few studies have explored whether staff within non-medical environments feel prepared to support early ACP engagement for persons with early-stage dementia and their families. Our qualitative interpretivist study aimed to fill this gap by facilitating, transcribing and thematically analyzing deliberations from three focus groups with 17 community-based staff. Our findings revealed four key barriers to ACP activation in community settings: (1) the stigma associated with the condition; (2) lack of knowledge about end-of-life concerns for persons with dementia; (3) uncertainties about managing complex family dynamics and (4) worries that opening up conversations about future care may lead to the expression of wishes that could not be actualized (e.g., dying at home). Our findings further revealed that ACP engagement was facilitated when staff expressed confidence in their capacities to gauge readiness, viewed themselves as guides rather than experts and had access to resources to supplement their knowledge. Reflexive training opportunities and access to materials and resources around end-of-life care for persons with dementia, could equip staff in these non-medical settings with the skills to engage in ongoing dialogue about future care issues with persons living with dementia and their families.

Barriers and facilitators to multidimensional symptom management in palliative care: A focus group study among patient representatives and clinicians

OBJECTIVES

It is widely acknowledged that co-occurring symptoms in patients with a psychosocial and spiritual aspects should also be considered. However, this multidimensional approach is difficult to integrate into daily practice, especially for generalist clinicians not specialized in palliative care. We aimed to identify the barriers and facilitators to multidimensional symptom management.

METHODS

Focus group meetings were conducted with the following stakeholders: (1) patient representatives, (2) generalist community nurses, (3) generalist hospital nurses, (4) general practitioners, (5) generalist hospital physicians, and (6) palliative care specialists. Audiotapes were transcribed verbatim and thematically analyzed.

RESULTS

Fifty-one participants (6-12 per group) reported barriers and facilitators with 3 main themes: multidimensional symptom assessment, initiating management of nonphysical problems, and multidisciplinary collaboration. As barriers, generalist clinicians and palliative care specialists reported that generalist clinicians often lack the communication skills to address nonphysical problems and are unaware of available resources for multidimensional symptom management. Palliative care specialists felt that generalist clinicians may be unaware that assessing nonphysical problems is important and focus on pharmacological interventions. Generalist nurses and palliative care specialists indicated that hierarchical difficulties between them and generalist physicians are barriers to multidisciplinary collaboration. Reported facilitators included using symptom assessment scales and standardized questions on nonphysical problems.

SIGNIFICANCE OF RESULTS

Generalist clinicians can be supported by improving their communication skills, increasing their awareness of available resources for multidimensional symptom management, and by using a standardized approach to assess all 4 dimensions of palliative care.

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.

Clinical nurse specialist role in providing generalist and specialist palliative care: A qualitative study of mesothelioma clinical nurse specialists

Aim

To explore perspectives of Mesothelioma UK clinical nurse specialists (CNSs) on their role in providing palliative care for patients with mesothelioma and their families.

Design

A qualitative descriptive approach using focus group and interview methods.

Methods

Focus groups and semi‐structured interviews were conducted with 16 Mesothelioma UK clinical nurse specialists using the online software Google Meet. Data collection was carried out in Jan‐Feb 2021 and data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research (COREQ) was used as the reporting guideline for this paper.

Results

Four main themes were identified from the data: Mesothelioma UK clinical nurse specialist role in relation to palliative care; joint working with specialist palliative care and community services; patients and family carer's willingness to engage with palliative care services; and the impact of COVID‐19 on palliative care for mesothelioma patients.

Conclusion

This study provides valuable insights into palliative care needs in mesothelioma. Patients with mesothelioma and their families have significant palliative care needs throughout the course of their illness from diagnosis to the end of life. Mesothelioma UK CNS's play a crucial role in supporting patients' and families palliative care needs, and are highly skilled in providing this care.

Impact

By acknowledging the role of Mesothelioma UK CNS's in palliative care provision, and supporting collaborative working between specialist and generalist palliative care providers, there is the capacity to significantly improve palliative care in mesothelioma and improve outcomes for patients and their families.

Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey

BACKGROUND

Primary healthcare teams (general practice and community nursing services) within the United Kingdom provided the majority of community end-of-life care during COVID-19, alongside specialist palliative care services. As international healthcare systems move to a period of restoration following the first phases of the pandemic, the impact of rapidly-implemented service changes and innovations across primary and specialist palliative care services must be understood.

AIM

To provide detailed insights and understanding into service changes and innovation that occurred in UK primary care to deliver end-of-life care during the first phase of the COVID-19 pandemic.

DESIGN

Cross-sectional online survey. Responses were analysed using descriptive statistics and thematic analysis.

SETTING/PARTICIPANTS

United Kingdom survey of general practitioners and community nurses, circulated via regional and national professional networks.

RESULTS

A total of 559 valid responses were received from 387 community nurses, 156 general practitioners and 16 'other'. Over a third of respondents (n = 224; 40.8%) experienced changes in the organisation of their team in order to provide end-of-life care in response to the COVID-19 pandemic. Three qualitative themes were identified: COVID-19 as a catalyst for change in primary palliative care; new opportunities for more responsive and technological ways of working; and pandemic factors that improved and strengthened interprofessional collaboration.

CONCLUSION

Opportunity has arisen to incorporate cross-boundary service changes and innovations, implemented rapidly at the time of crisis, into future service delivery. Future research should focus on which service changes and innovations provide the most benefits, who for and how, within the context of increased patient need and complexity.

Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand

A generalist-specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers-Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that "generalists" are willing and able to play a key role in palliative care provision needs to be further challenged.

Palliative care physicians' motivations for models of practicing in the community: A qualitative descriptive study

BACKGROUND

Internationally, both primary care providers and palliative care specialists are required to address palliative care needs of our communities. Clarity on the roles of primary and specialist-level palliative care providers is needed in order to improve access to care. This study examines how community-based palliative care physicians apply their roles as palliative care specialists, what motivates them, and the impact that has on how they practice.

DESIGN

A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care specialists. We asked participants to describe their care processes and the factors that influence how they work.

SETTING/PARTICIPANTS

A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care physicians in Ontario, Canada was undertaken between March and June 2020. At interview end, participants indicated whether their practice approaches aligned with one or more models depicted in a conceptual framework that includes consultation (specialist provides recommendations to the family physician) and takeover (palliative care physician takes over all care responsibility from the family physician) models.

RESULTS

Of the 14 participants, 4 worked in a consultation model, 8 in a takeover model, and 2 were transitioning to a consultation model. Different motivators were found for the two practice models. In the takeover model, palliative care physicians were primarily motivated by their relationships with patients. In the consultation model, palliative care physicians were primarily motivated by their relationships with primary care. These differing motivations corresponded to differences in the day-to-day processes and outcomes of care.

CONCLUSIONS

The physician's personal or internal motivators were drivers in their practice style of takeover versus consultative palliative care models. Awareness of these motivations can aid our understanding of current models of care and help inform strategies to enhance consultative palliative care models.

International models of neuropalliative care

Can equitable Neuropalliative care (NpC) be delivered globally? This chapter surveys existing services and ground realities in different parts of the world. In many countries, universal healthcare (UHC) seems to have been a precondition for the establishment of palliative care (PC). PC has been recognized as a basic human right as a part of UHC. Quality of Death and PC surveys provide an overview of the existing situation. Currently, PC is largely focused on the needs of cancer patients and this is a legacy issue for professionals and systems. Communities however recognize suffering and do not distinguish between medical diagnoses. The development of NpC as a subspecialty of neurology allows neurologists everywhere to become primary palliative care providers for their own patients. It is also necessary to integrate neurology with existing palliative care services. There is much that can be done to improve NpC provision even within the limits that bound every jurisdiction and trial evidence is emerging to inform this practice. This chapter is a survey of the challenges and the potential.

Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis

BACKGROUND

Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care.

METHODS

This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised.

RESULTS

Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care.

CONCLUSION

There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.

Cultures that collide: an ethnographic study of the introduction of a palliative care consultation team on acute wards

Background

Acute care and palliative care (PC) are described as different incompatible organisational care cultures. Few studies have observed the actual meeting between these two cultures. In this paper we report part of ethnographic results from an intervention study where a palliative care consultation team (PCCT) used an integrative bedside education approach, trying to embed PC principles and interventions into daily practice in acute wards.

Purpose

To study the meeting and interaction of two different care cultures, palliative care and curative acute wards, when a PCCT introduces consulting services to acute wards regarding end-of-life palliative care, focusing on the differences between the cultures.

Methods

An ethnographic study design was used, including observations, interviews and diary entries. A PCCT visited acute care wards during 1 year. The analysis was inspired by Spradleys ethnography.

Results

Three themes were found: 1) Anticipations meets reality; 2) Valuation of time and prioritising; and 3) The content and creation of palliative care.

Conclusion

There are many differences in values, and the way PC are provided in the acute care wards compared to what a PCCT expects. The didactic challenges are many and the PC require effort.

Transitioning end-of-life care from hospital to the community: case report

Palliative/end-of-life care is an integral part of the district nursing service. There is increasing demand for palliative care to be delivered in the community setting. Therefore, there is a need for excellent collaboration between staff in primary and secondary care settings to achieve optimum care for patients. This article critically analyses the care delivered for a palliative patient in the hospital setting and his subsequent transition to the community setting. The importance of effective communication, holistic assessment in palliative care, advance care planning, organisational structures and the socio-cultural aspects of caring for patients at the end of life are discussed. Additionally, the article highlights the impact of substandard assessment and communication and the consequent effect on patients and families.

Impact of physician-based palliative care delivery models on health care utilization outcomes: A population-based retrospective cohort study

BACKGROUND

Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes.

AIM

To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death.

DESIGN

Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death.

SETTING/PARTICIPANTS

All adults aged 18-105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017.

RESULTS

Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%-59%), acute hospitalization (64%-69%) or ICU admission (7%-17%), as well as community death (36%-40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4-9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9-2.0).

CONCLUSION

The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.

Understanding the palliative care needs and experiences of people with mesothelioma and their family carers: An integrative systematic review

BACKGROUND

People with mesothelioma and their families have palliative care needs throughout the relatively short trajectory of their illness.

AIM

To describe the palliative care needs and experiences of people with mesothelioma and their family carers.

DESIGN

Integrative systematic review with narrative synthesis (PROSPERO: CRD42020190115).

DATA SOURCES

MEDLINE, CINAHL, PsycINFO and the Cochrane Library were searched for articles published between 01 January 2000 and 10 May 2020. Articles were included if they presented empirical studies or comprehensive reviews including information about the palliative care needs and experiences of people with mesothelioma and their family carers.

RESULTS

The search yielded 508 articles, 14 were included in the analysis. A cross cutting theme of 'uncertainty' was identified encompassing five themes: (1) organisation and co-ordination of services, (2) communication and information needs, (3) management of care needs and high symptom burden, (4) consideration of the impact of seeking compensation and (5) family carer needs. Our findings demonstrate that people with mesothelioma want a co-ordinated, team-based approach to palliative care with a named point of contact. Whilst carers value and benefit from early referral to specialist palliative care, this does not necessarily reflect the outcomes and views of patients.

CONCLUSION

The evidence base around the palliative care needs and experiences of people with mesothelioma and their carers needs to be strengthened. The results of this review support the need to develop a greater understanding about the role non-specialist palliative care clinicians' play in providing generalist palliative care for people with mesothelioma and their carers.

A Qualitative Study Exploring Patient, Family Carer and Healthcare Professionals' Direct Experiences and Barriers to Providing and Integrating Palliative Care for Advanced Head and Neck Cancer

OBJECTIVES

To report on direct experiences from advanced head and neck cancer patients, family carers and healthcare professionals, and the barriers to integrating specialist palliative care.

METHODS

Using a naturalistic, interpretative approach, within Northwest England, a purposive sample of adult head and neck cancer patients was selected. Their family carers were invited to participate. Healthcare professionals (representing head and neck surgery and specialist nursing; oncology; specialist palliative care; general practice and community nursing) were recruited. All participants underwent face-to-face or telephone interviews. A thematic approach, using a modified version of Colazzi's framework, was used to analyze the data.

RESULTS

Seventeen interviews were conducted (9 patients, 4 joint with family carers and 8 healthcare professionals). Two main barriers were identified by healthcare professionals: "lack of consensus about timing of Specialist Palliative Care engagement" and "high stake decisions with uncertainty about treatment outcome." The main barrier identified by patients and family carers was "lack of preparedness when transitioning from curable to incurable disease." There were 2 overlapping themes from both groups: "uncertainty about meeting psychological needs" and "misconceptions of palliative care."

CONCLUSIONS

Head and neck cancer has a less predictable disease trajectory, where complex decisions are made and treatment outcomes are less certain. Specific focus is needed to define the optimal way to initiate Specialist Palliative Care referrals which may differ from those used for the wider cancer population. Clearer ways to effectively communicate goals of care are required potentially involving collaboration between Specialist Palliative Care and the wider head and neck cancer team.

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

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.

Sharing Cancer Survivorship Care between Oncology and Primary Care Providers: A Qualitative Study of Health Care Professionals' Experiences

Survivorship care that is shared between oncology and primary care providers may be a suitable model to effectively and efficiently care for the growing survivor population, however recommendations supporting implementation are lacking. This qualitative study aimed to explore health care professionals’ (HCPs) perceived facilitators and barriers to the implementation, delivery and sustainability of shared survivorship care. Data were collected via semi-structured focus groups and analysed by inductive thematic analysis. Results identified four overarching themes: (1) considerations for HCPs; (2) considerations regarding patients; (3) considerations for planning and process; and (4) policy implications. For HCPs, subthemes included general practitioner (GP, primary care physician) knowledge and need for further training, having clear protocols for follow-up, and direct communication channels between providers. Patient considerations included identifying patients suitable for shared care, discussing shared care with patients early in their cancer journey, and patients’ relationships with their GPs. Regarding process, subthemes included rapid referral pathways back to hospital, care coordination, and ongoing data collection to inform refinement of a dynamic model. Finally, policy implications included development of policy to support a consistent shared care model, and reliable and sustainable funding mechanisms. Based on study findings, a set of recommendations for practice and policy were developed.

Feasibility of the PalliSupport care pathway: results from a mixed-method study in acutely hospitalized older patients at the end of life

BACKGROUND

A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial.

METHODS

A mixed-method feasibility study was conducted at one hospital with affiliated primary care. Patients were ≥ 60 years and acutely hospitalized. The intervention consisted of (1) training on early identification of the palliative phase and end of life conversations, (2) involvement of a transitional palliative care team during admission and post-discharge and (3) intensified collaboration between care settings. Outcomes were feasibility of recruitment, data collection, patient burden and protocol adherence. Experiences of 14 professionals were assessed through qualitative interviews.

RESULTS

Only 16% of anticipated participants were included which resulted in difficulty assessing other feasibility criteria. The qualitative analysis identified misunderstandings about palliative care, uncertainty about professionals' roles and difficulties in initiating end of life conversations as barriers. The training program was well received and professionals found the intensified collaboration beneficial for patient care. The patients that participated experienced low burden and data collection on primary outcomes and protocol adherence seems feasible.

DISCUSSION

This study highlights the importance of performing a feasibility study prior to embarking on effectiveness studies. Moving forward, the PalliSupport care pathway will be adjusted to incorporate a more active recruitment approach, additional training on identification and palliative care, and further improvement on data collection.

Facilitators and barriers to shared primary and specialist cancer care: a systematic review

PURPOSE

To care for the growing population of cancer survivors, health services worldwide must reconsider how to deliver care to people living with and beyond a cancer diagnosis. Shared care, defined as cancer care that is shared between specialist and primary care providers, is one model that has been investigated; however, practical guidance to support implementation is lacking. This systematic review aimed to explore facilitators and barriers to implementing shared cancer care and to develop practice and policy recommendations to support implementation.

METHODS

A systematic literature search was conducted in June 2019 across MEDLINE, Embase, Emcare, and PsycINFO databases. Quantitative and qualitative data relevant to the review question were extracted and synthesized following a mixed methods approach.

RESULTS

Thirteen papers were included in the review, 10 qualitative and three quantitative. Included articles were from Australia (n = 8), the USA (n = 3), and one each from the UK and the Netherlands. Sixteen themes were developed under four categories of patient, healthcare professional, process, and policy factors. Key themes included the perceived need for primary care provider training, having clearly defined roles for each healthcare provider, providing general practitioners with diagnostic and treatment summaries, as well as protocols or guidelines for follow-up care, ensuring rapid and accurate communication between providers, utilizing electronic medical records and survivorship care plans as communication tools, and developing consistent policy to reduce fragmentation across services.

CONCLUSION

Recommendations for practice and policy were generated based on review findings that may support broader implementation of shared cancer care.

Factors influencing GPs' perception of specialised palliative homecare (SPHC) importance - results of a cross-sectional study

Background

General Practitioners (GPs) are the main providers of primary palliative care (PPC). At the same time they are the main initiators of specialised palliative homecare (SPHC). In Germany, little is known about factors which influence GPs in their involvement of SPHC. Aim of our study is to identify factors that drive GPs to give value to and involve SPHC.

Methods

A cross-sectional survey was performed. In 2018, questionnaires were mailed to 6000 randomly selected GPs from eight German federal states, focusing on the extent of GPs’ palliative care activities and their involvement of SPHC.

Results

With a response rate of 19.4% and exclusion of GPs working in SPHC-teams, n = 1026 questionnaires were appropriate for analysis. GPs valued SPHC support as the most “important/very important” for both “technical/invasive treatment measures” (95%) and availability outside practice opening hours (92%).

The most relevant factor influencing perceived SPHC-importance was GPs’ self-reported extent of engagement in palliative care (β = − 0.283; CI 95% = − 0.384;−0.182), followed by the perceived quality of utilised SPHC (β = 0.119; CI 95% = 0.048;0.190), involvement in treatment of palliative patients after SPHC initiation (β = 0.088; CI 95% = 0.042;0.134), and conviction that palliative care should be a central part of GPs’ work (β = − 0.062; CI 95% = − 0.116;−0.008). Perceived SPHC-importance is also associated with SPHC-referrals (β =0.138; p < 0.001). The lower the engagement of GPs in palliative care, the more they involve SPHC and vice versa.

Conclusions

GPs with low reported activity in palliative care are more likely to initialise SPHC for palliative care activities they do not deliver themselves for various reasons, which might mean that the involvement of SPHC is substitutive instead of complementary to primary palliative care. This finding and its interpretation should be given more attention in the future policy framework for (specialised) palliative homecare.

Trial registration

German Clinical Trials Register DRKS00014726, 14.05.2018.

Health Care Providers' Views on the Transition Between Hospital and Primary Care in Patients in the Palliative Phase: A Qualitative Description Study

CONTEXT

Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals.

OBJECTIVES

To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care.

METHODS

This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically.

RESULTS

The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process.

CONCLUSION

Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

Healthcare providers' views and experiences of non-specialist palliative care in hospitals: A qualitative systematic review and thematic synthesis

BACKGROUND

Healthcare providers working in hospitals are frequently exposed to patients with palliative care needs. For most patients, these reflect non-specialist rather than specialist palliative care needs. Embedding palliative care principles early in patients' disease trajectories within acute care delivery in hospitals, however, is a challenge. How to best understand the experiences of those providing non-specialist palliative care in hospitals has not been systematically assessed.

AIM

To synthesise the evidence on healthcare providers' views and experiences of non-specialist palliative care in hospitals.

DESIGN

A qualitative systematic review and thematic synthesis using Thomas and Harden's thematic synthesis framework.

DATA SOURCES

Databases of MEDLINE, CINAHL, PsycINFO and EMBASE were searched from date of inception to March 2018. Studies were eligible for inclusion if they reported on healthcare providers' views and experiences of non-specialist palliative care in hospitals. Studies were appraised for quality but not excluded on that basis. The review was prospectively registered with the International Prospective Register of Systematic Reviews.

RESULTS

Thirty-nine papers of 37 studies were included, representing 985 hospital healthcare providers' views and experiences. Four major analytical themes emerged; 'Understanding of Palliative Care', 'Complexities of Communication', 'Hospital Ecosystem' and 'Doctors and Nurses - a Different Lens'.

CONCLUSIONS

Non-specialist palliative care in hospitals is operationalised as care in the last weeks and days of life. The organisation of acute care, inter-disciplinary working practices, clinician attitudes, poor communication structures and lack of education and training in palliative care principles exacerbates poor implementation of this care earlier for patients in hospitals.

General Practitioners' Perspectives on General and Specialized Palliative Home Care in North Rhine, Germany: An Explorative Focus Group Study

BACKGROUND

General practitioners (GPs) are important providers and coordinators of palliative home care (PHC). Through this double role, their perspectives and their treatment decisions influence PHC fundamentally. This study aims to gain deeper insights into GPs' perspectives regarding PHC in North Rhine, Germany.

METHODS

An explorative, semistructured focus group was conducted with 7 doctors. The researchers performed content analysis. Main topics were GPs' role definition in PHC and GPs' medical activities in PHC.

RESULTS

Participating GPs describe their role in PHC, based on high motivation and positive attitudes toward PHC as a hybrid role: coordinator, provider (mostly in general PHC), and referrer (gateway to palliative care [PC] specialists). According to GPs' medical activity, participants describe moderate expertise, demanding tasks, and elaborate PHC provision for GPs. Participants stressed the importance of PC in GPs' work. But also PC is a small field in general practice. GPs' PHC benefits from the deep trust resulting from the often close and long-term GP-patient relationship. Complexity and bureaucracy of PHC structures as well as the lack of resources and multidisciplinary cooperation are named as barriers for providing PHC. The highest level of care is reached in specialized PHC, which only very few, severely impaired patients need.

CONCLUSIONS

Participating GPs see themselves as important PHC providers as well as referrers and coordinators. Complexity and discontinuity in PC arrangements create challenges for their provision. Therefore, they long for reduced bureaucratic burdens.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study

BACKGROUND

Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings.

METHODS

This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes.

RESULTS

There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings.

INTERPRETATION

Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

The Overlap Between Geriatric Medicine and Palliative Care: A Scoping Literature Review

With an increasing aging population worldwide, there is a growing need for both palliative care and geriatric medicine. It is presumed in medical literature that both specialties share similar goals about patient care and could collaborate. To inform future service development, the objective of this review was to identify what is currently empirically known about overlapping working practices. This article provides a scoping literature review on the relationship between geriatric medicine and palliative care within the United Kingdom. The review encompassed literature written between 1997 and 2019 accessed via Scopus, Web of Science, PubMed, and Google Scholar. Three themes were identified: (a) unclear boundaries between specialties, (b) communication within and between specialisms, and (c) ambiguity of how older people fit in the current health care system. We suggest that more empirical research is conducted about the overlap between palliative care and geriatric medicine to understand how interprofessional working and patient care can be improved.

Integrated primary palliative care model; facilitators and challenges of primary care/family physicians providing community-based palliative care

Introduction:

Patients with advanced cancer often suffer from complex symptoms necessitating constant supervision and management. Primary care/family physicians act as an important bridge between the patients in the community and the specialists in the hospital ensuring continuity of care.

Materials and Methods:

The present paper explored the facilitators and challenges in providing home-based palliative care as perceived by the primary care/family physicians (PCP/FP).

Results:

62 physicians reported that they were involved in palliative management of at least one cancer patient in the previous year. A significant number of GPs (34%) lacked confidence in providing this care because of patient complexity, inadequate training and insufficient resources. Other barriers included poor communication from specialists and treating teams. Factors facilitating provision of home-based palliative care included their willingness to help palliative care patients, their inclination to train in palliative care and enthusiasm to refer to guidelines while caring for patients.

Conclusion:

It is explicit in the paper that resources with respect to information sharing and communication, technical support and training are essential to empower the PCP/FP in providing community-based palliative care.

Australian GPs' perceptions of barriers and enablers to best practice palliative care: a qualitative study

BACKGROUND

General Practitioners (GPs) often play an important role in caring for people at the end of life. While some international studies suggest that GPs experience a number of barriers to providing palliative care, little is known about views and experiences of GPs in Australia. This study explored Australian GPs' perceptions of barriers and enablers to the provision of palliative care and provides new insights into how to implement best practice care at the end of life.

METHODS

This was a qualitative study using 25 semi-structured phone interviews conducted with GPs practising in metropolitan and non-metropolitan New South Wales, Australia. Data were analysed using qualitative content analysis.

RESULTS

GPs reported difficulties with palliative care provision due to i) the complex and often emotional nature of doctor-family-interaction; ii) a lack of evidence to guide care; and iii) the need to negotiate roles and responsibilities within the healthcare team. GPs listed a number of strategies to help deal with their workload and to improve communication processes between healthcare providers. These included appropriate scheduling of appointments, locally tailored mentoring and further education, and palliative care guidelines which more clearly outline the roles and responsibilities within multidisciplinary teams. GPs also noted the importance of online platforms to facilitate their communication with patients, their families and other healthcare providers, and to provide centralised access to locally tailored information on palliative care services. GPs suggested that non-government organisations could play an important role by raising awareness of the key role of GPs in palliative care provision and implementing an "official visitor" program, i.e. supporting volunteers to provide peer support or respite to people with palliative care needs and their families.

CONCLUSIONS

This study offers new insights into strategies to overcome well documented barriers to palliative care provision in general practice and help implement optimal care at the end of life. The results suggest that researchers and policy makers should adopt a comprehensive approach to improving the provision of palliative care which tackles the array of barriers and enablers identified in this study.

General practitioners' perceptions of best practice care at the end of life: a qualitative study

BACKGROUND

GPs can play a central role in palliative care delivery. However, little is known about their views on what constitutes best practice care at the end of life.

AIM

To explore, in a sample of Australian GPs, their perceptions of best practice palliative care and their ideal role in its delivery.

DESIGN & SETTING

A qualitative interview study of 25 GPs practising in metropolitan and non-metropolitan locations in New South Wales, Australia.

METHOD

Semi-structured telephone interviews were conducted. Data were analysed using qualitative content analysis.

RESULTS

Participants had a mean age of 51 years, and had practised between 3 and 38 years (mean 19 years). Best practice palliative care was perceived to be proactive and responsive to a wide range of patient and family needs. Many participants indicated a need for relational continuity, which involves GPs establishing a care pathway from diagnosis to palliation, coordinating care across the pathway, and collaborating with other healthcare providers. A number of participants perceived palliative care as a natural extension of primary care and indicated that best practice palliative care mainly requires experiential knowledge and good communication skills, rather than specialised medical knowledge. Participants listed a number of communication strategies to offer patients and their families choice and ongoing negotiation about the recommended treatments.

CONCLUSION

This study provides novel in-depth insights into GPs' perceptions of best practice palliative care. Future research should further investigate the identified features of care, and whether they can maximise the outcomes of patients and their families.

Systematic review of barriers and enablers to the delivery of palliative care by primary care practitioners

BACKGROUND

There is increasing demand for primary care practitioners to play a key role in palliative care delivery. Given this, it is important to understand their perceptions of the barriers and enablers to optimal palliative care, and how commonly these are experienced.

AIM

To explore the type and prevalence of barriers and enablers to palliative care provision reported by primary care practitioners.

DESIGN

A systematic review of quantitative data-based articles was conducted.

DATA SOURCES

Medline, Embase and PsychINFO databases were searched for articles published between January 2007 and March 2019.

DATA SYNTHESIS

Abstracts were assessed against the eligibility criteria by one reviewer and a random sample of 80 articles were blind coded by a second author. Data were extracted from eligible full-texts by one author and checked by a second. Given the heterogeneity in the included studies' methods and outcomes, a narrative synthesis was undertaken.

RESULTS

Twenty-one studies met the inclusion criteria. The most common barriers related to bureaucratic procedures, communication between healthcare professionals, primary care practitioners' personal commitments, and their skills or confidence. The most common enablers related to education, nurses and trained respite staff to assist with care delivery, better communication between professionals, and templates to facilitate referral to out-of-hours services.

CONCLUSION

A holistic approach addressing the range of barriers reported in this review is needed to support primary care providers to deliver palliative care. This includes better training and addressing barriers related to the interface between healthcare services.

Accessing palliative care for multiple sclerosis: A qualitative study of a neglected neurological disease

BACKGROUND

Despite the global consensus on the importance of palliative care for patients with multiple sclerosis (MS), many patients in developing countries do not receive palliative care. Improving access to palliative care for MS requires a contextual understanding of how palliative care is perceived by patients and health professionals, the existing care pathways, and barriers to the provision of palliative care.

OBJECTIVE

This study aims to examine and contrast the perceptions of MS patients, neurologists, and palliative care physicians towards providing palliative care for patients with MS in Malaysia.

METHODS

12 MS patients, 5 neurologists, and 5 palliative care physicians participated in this qualitative study. Each participant took part in a semi-structured interview. The interviews were transcribed verbatim, and analysed using an iterative thematic analysis approach.

RESULTS

Patients and neurologists mostly associated palliative care with the end-of-life and struggled to understand the need for palliative care in MS. Another barrier was the lack of understanding about the palliative care needs of MS patients. Palliative care physicians also identified the scarcity of resources and their lack of experience with MS as barriers. The current referral-based care pathway itself was found to be a barrier to the provision of palliative care.

CONCLUSIONS

MS patients in Malaysia face several barriers in accessing palliative care. Overcoming these barriers will require improving the shared understanding of palliative care and its role in MS. The existing care pathway also needs to be reformed to ensure that it improves access to palliative care for MS patients.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Impact of informational and relational continuity for people with palliative care needs: a mixed methods rapid review

OBJECTIVE

To identify and synthesise existing literature exploring the impact of relational and informational continuity of care on preferred place of death, hospital admissions and satisfaction for palliative care patients in qualitative, quantitative and mixed methods literature.

DESIGN

A mixed methods rapid review.

METHODS

PUBMED, PsychINFO, CINAHL were searched from June 2008 to June 2018 in order to identify original peer reviewed, primary qualitative, quantitative or mixed methods research exploring the impact of continuity of care for people receiving palliative care. Synthesis methods as outlined by the Cochrane Qualitative and Implementation Methods Group were applied to qualitative studies while meta-analyses for quantitative data were planned.

OUTCOMES

The impact of interventions designed to promote continuity of care for people receiving palliative care on the following outcomes was explored: achieving preferred place of death, satisfaction with care and avoidable hospital admissions.

RESULTS

18 eligible papers were identified (11 qualitative, 6 quantitative and 1 mixed methods papers). In all, 1951 patients and 190 family caregivers were recruited across included studies. Meta-analyses were not possible due to heterogeneity in outcome measures and tools used. Two studies described positive impact on facilitating preferred place of death. Four described a reduction in avoidable hospital admissions. No negative impacts of interventions designed to promote continuity were reported. Patient satisfaction was not assessed in quantitative studies. Participants described a significant impact on their experiences as a result of the lack of informational and relational continuity.

CONCLUSIONS

This rapid review highlights the impact that continuity of care can have on the experiences of patients receiving palliative care. The evidence for the impact of continuity on place of death and hospital admissions is limited. Methods for enhancing, and recording continuity should be considered in the design and development of future healthcare interventions to support people receiving palliative care.

Factors Associated with Fulfilling the Preference for Dying at Home among Cancer Patients: The role of General Practitioners

Aim: This study aimed to explore clinical and care-related factors associated with fulfilling cancer patients’ preference for home death across four countries: Belgium (BE), the Netherlands (NL), Italy (IT), and Spain (ES). Methods: A mortality follow-back study was undertaken from 2009 to 2011 via representative networks of general practitioners (GPs). The study included all patients aged 18 and over who had died of cancer and whose home death preference and place of death were known by the GP. Factors associated with meeting home death preference were tested using multivariable logistic regressions. Results: Among 2,048 deceased patients, preferred and actual place of death was known in 42.6 percent of cases. Home death preference met ranged from 65.5 to 90.9 percent. Country-specific factors included older age in BE, and decisionmaking capacity and being female in the NL GPs’ provision of palliative care was positively associated with meeting home death preference. Odds ratios (ORs) were: BE: 9.9 (95 percent confidence interval [CI] 3.7–26.6); NL: 9.7 (2.4–39.9); and IT: 2.6 (1.2–5.5). ORs for Spain are not shown because a multivariate model was not performed. Conclusion: Those who develop policy to facilitate home death need to examine available resources for primary end-of-life care.

But: Cette étude avait pour objectif d'examiner les facteurs cliniques associés aux demandes des patients désirant mourir à la maison. Cette re-cherche s'étendait sur quatre pays soit la Belgique, les Pays-Bas, l'Italie, et l'Espagne. Méthode: Par l'inter-médaire des réseaux représentatifs d'omnipraticiens, nous avons pu faire un suivi rétrospectif des mortalités survenues durant les années 2009, 2010, et 2011. Cette étude comprenait les patients agés de 18 ans et plus morts du cancer et dont les médecins connaissaient tout autant les volontés de pouvoir mourir à la maison que l'endroit où les patients étaient morts. Les facteurs correspondants aux préférences des patients ont été validés à l'aide de la méthode statistique de regression logistique à variables multiples. Résultats: Parmi les 2 048 personnes décédées on connaissait, chez 42,6 pourcent d'entre elles, la préférence et l'endroit de la mort. Le choix de mourir à domicile variait de 65,5 pourcent à 90,9 pourcent. Les facteurs spécifiques à certains pays étaient l'âge avancé pour la Belgique et, pour les Pays-Bas, la capacité décisionnelle et le fait d'être de sexe feminin. La prestation des soins palliatifs par les omnipraticiens est associée de façon positive au choix de mourir à la maison. Les rapports de probabilités étaient les suivants: Belgique: 9,9 [95 pourcent d'intervalle de fiabilité (3,7–26,6)], Pays-Bas: 9,7 (2,4–39,9) et l'Italie: 2,6 (1,2–5,5). Les facteurs de probabilité pour l'Espagne ne sont pas indiqués car on n'a pas fait d'analyse selon le modèle multivariable. Conclusion: Les professionnels de la santé ayant pour tâche d'établir les politiques pour faciliter la mort à la maison doivent connnaître toutes les resources dont ils disposent dans leur communauté afin de pouvoir offrir les soins de première ligne à domicile.

Primary palliative care team perspectives on coordinating and managing people with advanced cancer in the community: a qualitative study

Background

Primary health care teams are key to the delivery of care for patients with advanced cancer during the last year of life. The Gold Standards Framework is proposed as a mechanism for coordinating and guiding identification, assessment, and support. There are still considerable variations in practice despite its introduction. The aim of this qualitative study is to improve understanding of variations in practice through exploring the perspectives and experiences of members of primary health care teams involved in the care of patients with advanced cancer.

Methods

Qualitative, semi-structured interviews, focus groups, and non-participatory observations involving 67 members of primary health care teams providing palliative care. Data were analysed using a grounded theory approach.

Results

We identified distinct differences in the drivers and barriers of community advanced cancer care coordination, which relate to identification and management, and access to effective pain management, and go some way to understanding variations in practice. These include proactive identification processes, time and resource pressures, unclear roles and responsibilities, poor multidisciplinary working, and inflexible models for referral and prescribing. These provide valuable insight into how professionals work together and independently within an infrastructure that can both support and hinder the provision of effective community palliative care.

Conclusions

Whilst the GSF is a guide for good practice, alone it is not a mechanism for change. Rather it provides a framework for describing quality of practice that was already occurring. Consequently, there will continue to be variations in practice.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0861-z) contains supplementary material, which is available to authorized users.

[Nurses' perspectives on outpatient palliative care in Vorarlberg, Austria]

BACKGROUND

Due to the demographic development the need for palliative care in the outpatient setting will increase and challenge general practitioners and community nurses.

AIM

This study investigated the state of outpatient palliative care in Vorarlberg, Austria from the perspective of outpatient community nurses. The key points of the survey covered the burden of symptoms suffered by palliative patients. Another key focus was the cooperation and communication between community nurses and general practitioners.

METHODS

Between 8 February and 7 March 2016 all 50 community-based nursing services in Vorarlberg were invited to participate in an online survey designed to estimate outpatient palliative care. The survey collected quantitative and descriptive data and 38 nursing services returned the questionnaire (76 %).

RESULTS

According to community-based nurses, the proportion of patients in need of palliative care was 5.7 %. This assessment of needs correlates well with the proportion of personnel qualified in palliative care (p = 0.02). Nursing personnel estimated a high prevalence of symptom burden (76 %). Communication between outpatient nursing personnel and general practitioners relied primarily on telephone calls (79-90 %), less on joint rounds (13-21 %) and case reviews (26-45 %). According to 63 % of the nursing personnel the rate of hospitalization could be reduced with better interprofessional cooperation.

DISCUSSION

Symptom burden in the outpatient setting was similar to that of patients being cared for in hospitals. Healthcare personnel in general palliative care should be adequately qualified. The quality of communication via telephone calls should be critically examined in further studies.