How do physicians and nurses in family practice describe their care for patients with progressive life-limiting illness? A qualitative study of a ‘palliative approach’

Abstract

Aim: To explore how a palliative approach to care is operationalized in primary care, through the description of clinical practices used by primary care clinicians to identify and care for patients with progressive life-limiting illness (PLLI). Background: Increasing numbers of people are living with PLLI but are often not recognized as needing a palliative approach to care. To meet growing needs, generalists such as family physicians will need to adopt a palliative approach to care in their own setting. Practical descriptions of a palliative approach in non-specialist settings have been lacking. Methods: We conducted a qualitative descriptive study design using in-depth semi-structured interviews with 11 key informant participants (6 physicians, 3 nurse practitioners, 1 registered nurse, and 1 registered practical nurse) known to be providing comprehensive care to patients with PLLI in family practices in Ontario, Canada. We asked about their approach to identifying patients with PLLI and the strategies used in their care. We employed content analysis to develop themes. Findings: Participants identified patients by functional decline, change in needs, increased acuity, and the specifics of a condition/diagnosis. Care strategies included concretizing commitment to care, eliciting goals of care, shifting care to the home, broadening team members including leveraging the support of family and community resources, and shifting to a ‘proactive’ approach involving increased follow-up, flexibility, and intensity. Conclusion: Primary care providers articulated strategies for identifying and providing care to patients with PLLI that illuminate an upstream approach tailored to their setting.

Description of a Palliative Approach to Care to Patients in the Last Year of Life in a Primary Care Setting

“…Documentation of advance care planning discussions, clinic and community nursing involvement, addressing psychosocial and spiritual needs and addressing caregiver wellness were care processes that distinguished between patients receiving PAC and not receiving PAC. In previous research, family physicians reported feeling capable of meeting the palliative needs of many patients, [2,35] however they have also reported doing so without a speci c plan or approach. [36] Patients with progressive life-limiting illness have varying needs over the last year of life, beyond medical treatment for physical symptoms.…”

“…There is increasing evidence revealing the bene ts of palliative care for patients with chronic, progressive life-limiting illness. [1][2][3][4][5] Fewer people are dying suddenly and most will live for a period of time with high healthcare and other needs. [6] Despite this knowledge, efforts to integrate, describe and evaluate palliative care in and across the healthcare system have not achieved the level of uptake and sustainability required.…”

“…[16,17] The phrase palliative approach has gained traction due to connotations of activities or tasks (not just philosophy) applicable to all care professionals (not just palliative care specialists) in a manner consistent with the philosophy of palliative care. [16] [18] Sawatzky and colleagues identi ed three overarching themes delineating a palliative approach: (1) upstream orientation towards the needs of people who have life-limiting conditions and their families, (2) adaptation of palliative care knowledge and expertise, (3) operationalization of a palliative approach through integration into systems and models of care that do not specialize in palliative care. [8] In Canada and elsewhere, it is recognized that family medicine is a specialty in which a primary palliative approach would be ideally situated [19,20] due to the provision of comprehensive care across the lifespan.…”

“…[18,25,28] To address the gap between conceptual descriptions and competencies, and observable measurable care processes in practice, in our previous work, we qualitatively described a palliative approach to care (PAC) in primary care, from the perspective of primary care physicians and nurses caring for patients with progressive life-limiting illnesses. [2] In this study, we sought to measure the extent to which PAC is provided in a large, urban inter-professional family health team (FHT) setting in one city in Canada. To assess the extent to which the outcomes resonated as a potential quality improvement opportunity, we also assessed the clinicians' perception of how consistently the FHT provides elements of PAC, before and after learning about the results.…”

Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada

“…To address the gap between conceptual descriptions and competencies, and observable measurable care processes in practice, in our previous work, we qualitatively described a palliative approach to care (PAC) in primary care, from the perspective of primary care physicians and nurses caring for patients with progressive life-limiting illnesses [ 2 ]. In this study, we sought to measure the extent to which PAC is provided in a large, urban inter-professional family health team (FHT) setting in one city in Canada.…”