Important treatment aims at the end of life: a nationwide study among GPs

Claessen, Susanne; Echteld, Michael A.; Francké, Anneke L.; Block, Lieve Van den; Donker, G.A.; Deliens, Luc

doi:10.3399/bjgp12x625184

Cited by 13 publications

(13 citation statements)

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“…Initially, curative, disease-modifying and life-prolonging treatments may be given alongside palliative treatments, with a gradual shift to an emphasis on palliation. However, a previous study in the Netherlands indicated that in practice the shift from curative and life-prolonging treatments towards palliation often occurs at a late stage in the disease trajectory [3], suggesting that sometimes GPs or other relevant professionals only recognize patients' need for palliative care late in the disease trajectory. However, timely recognition may be important in order to enable advance care planning and prevent crisis situations and unnecessary care transitions or hospital admissions.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2013

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BackgroundLittle is known about how GPs determine whether and when patients need palliative care. Little research has been done regarding the assumption underpinning Lynn and Adamson’s model that palliative care may start early in the course of the disease. This study was conducted to explore how GPs identify a need for palliative care in patients.MethodsA qualitative interview study was performed among 20 GPs in the Netherlands.ResultsGPs reported that a combination of several signals, often subtle and not explicit, made them identify a need for palliative care: signals from patients (increasing care dependency and not recuperating after intercurrent diseases) and signals from relatives or reports from medical specialists. GPs reported differences in how they identified a need for palliative care in cancer patients versus those with other diseases. In cancer patients, the need for palliative care was often relatively clear because of a relatively strict demarcation between the curative and palliative phase. However, in patients with e.g. COPD or in the very old, GPs' awareness of palliative care needs often arises gradually, relatively late in the disease trajectory.GPs consider the diagnosis of a life-threatening illness as a key point in the disease trajectory. However, this does not automatically mean that a patient needs palliative care at that point.ConclusionsGPs recognize a need for palliative care on the basis of various signals. They do not support the idea underlying Lynn and Adamson’s model that palliative care always starts early in the course of the disease.

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Section: Introductionmentioning

confidence: 99%

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

et al. 2013

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“…24 36 Curative or life prolonging interventions were ceased during that time for cancer patients 37 , but more likely in the last month in non-malignant patients. 37 Patients with cancer were more likely than those with non-malignant disease to have PC needs identified by a GP, 40 and more likely to receive care from clinical specialists, informal caregivers, allied health, and multidisciplinary palliative care services. 24 The unpredictable trajectory of the non-malignant conditions caused much of the uncertainty around timely PC referral.…”

Section: Providing Informationmentioning

confidence: 99%

“…Abarshi, 2010 37 The Netherlands Design: Cross-sectional survey Aim: To examine the incidence and timing of general practitioners (GPs) discussing end-of-life issues with patients whose deaths were expected Setting: General Practice • High self-reported involvement in EOLC 25…”

Section: Communication and Relationship Developmentmentioning

confidence: 99%

General practice physicians’ and nurses’ self-reported multidisciplinary end-of-life care: a systematic review

Senior

Grant

Rhee

et al. 2019

BMJ Support Palliat Care

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BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide end-of-life care (EoLC) as the population ages. To enhance primary palliative care (PC), the care they provide needs to be understood to inform best practice models of care.ObjectiveTo provide a comprehensive description of the self-reported role and performance of GPs and GPNs in (1) specific medical/nursing roles, (2) communication, (3) care co-ordination, (4) access and out-of-hours care, and (5) multidisciplinary care.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 29 reviewed papers reported the GPs’ and GPNs’ role in EoLC or PC practice. GPs report a central role in symptom management, treatment withdrawal, non-malignant disease management and terminal sedation. Information provision included breaking bad news, prognosis and place of death. Psychosocial concerns were often addressed. Quality of communication depended on GP–patient relationships and GP skills. Challenges were unrealistic patient and family expectations, family conflict and lack of advance care planning. GPs often delayed end-of-life discussions until 3 months before death. Home visits were common, but less so for urban, female and part-time GPs. GPs co-ordinated care with secondary care, but in some cases parallel care occurred. Trust in, and availability of, the GP was critical for shared care. There was minimal reference to GPNs’ roles.ConclusionsGPs play a critical role in palliative care. More work is required on the role of GPNs, case finding and models to promote shared care, home visits and out-of-hours services.

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“…However, home deaths substantially increase if the GP is aware in advance of the patient’s wish to die at home [6], if she/he pursues a palliative approach from the start [6], and when she/he cooperates with home care nurses and specialist palliative home care teams [7]. Yet, international research on GPs’ approach to care in the patient’s final months/weeks of life shows a combination of palliative measures with life-preserving actions (principally antibiotics and parenteral fluid) [8,9], even when the care setting has been labelled palliative [10]. The reasons why GPs resort to this combination have not yet been explored.…”

Section: Introductionmentioning

confidence: 99%

“…It might be that GPs’ transition from a mindset of life-preservation to one of palliation and “letting go” occurs (very) late in the terminal illness process [8]. Alternatively, the combination might also be triggered by the erratic course of terminal illnesses [9]. …”

Section: Introductionmentioning

confidence: 99%

“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

Sercu

Renterghem²,

Pype

et al. 2015

Scandinavian Journal of Primary Health Care

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Background Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs’ approach to care in patients’ final weeks of life showed a combination of palliative measures with life-preserving actions.Aim To explore the GP’s perspective on life-preserving versus “letting go” decision-making in EoL home care.Design Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care.Results Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient’s (quality of) life for the time being or to recognize the event as a step to life closure and “letting the patient go”. Making the “right” decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient’s clinical condition at the event itself, a GP’s level of determination in deciding and negotiating “letting go” and the patient’s/family’s wishes and preparedness regarding this death. Hospitalization was often a way out.Conclusions GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP’s burden considerably.Key PointsA late transition from a life-preserving mindset to one of “letting go” has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs’ perspectives on this matter.Not all GPs involved in EoL home care adopt a “letting go” mindset. For those who do, this mindset is challenged by the erratic course of terminal illness.GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events.Making the “right” decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.

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Important treatment aims at the end of life: a nationwide study among GPs

Cited by 13 publications

References 20 publications

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

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

General practice physicians’ and nurses’ self-reported multidisciplinary end-of-life care: a systematic review

“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

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