Advance care planning conversations with palliative patients: looking through the GP’s eyes

Abstract

BackgroundAlthough it is often recommended that general practitioners (GPs) initiate advance care planning (ACP), little is known about their experiences with ACP. This study aimed to identify GP experiences when conducting ACP conversations with palliative patients, and what factors influence these experiences.MethodsDutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis.ResultsFour themes were identified: ACP and society, the GP’s perceived role in ACP, initiating ACP and tailor-made ACP. ACP was regarded as a ‘hot topic’. At the same time, a tendency towards a society in which death is not a natural part of life was recognized, making it difficult to start ACP discussions. Interviewees perceived having ACP discussions as a typical GP task. They found initiating and timing ACP easier with proactive patients, e.g. who are anxious of losing capacity, and much more challenging when it concerned patients with COPD or heart failure. Patients still being treated in hospital posed another difficulty, because they often times are not open to discussion. Furthermore, interviewees emphasized that taking into account changing wishes and the fact that not everything can be anticipated, is of the utmost importance. Moreover, when patients are not open to ACP, at a certain point it should be granted that choosing not to know, for example about where things are going or what possible ways of care planning might be, is also a form of autonomy.ConclusionsACP currently is a hot topic, which has favourable as well as unfavourable effects. As GPs experience difficulties in initiating ACP if patients are being treated in the hospital, future research could focus on a multidisciplinary ACP approach and the role of medical specialists in ACP. Furthermore, when starting ACP with palliative patients, we recommend starting with current issues. In doing so, a start can be made with future issues kept in view. Although the tension between ACP’s focus on the patient’s direction and the right not to know can be difficult, ACP has to be tailored to each individual patient.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0868-5) contains supplementary material, which is available to authorized users.

Impact, challenges and limits of inpatient palliative care consultations – perspectives of requesting and conducting physicians

“…A previous study showed the importance of a valid explanation of the concept of PC beforehand [39], since without confronting patients with PC beforehand, they might still associate PC with oncoming death only [44]. However, there are of course patients who could benefit from PC, but cannot accept it, even after sufficient clarification [48].…”

End-of-life communication in advanced cancer: international trends (2009–2014)

“…In ES, for example, palliative care in hospitals has improved considerably over the course of this study, possibly leading to an increase in end-of-life conversations taking place in the hospital instead of the primary care setting 14. In the NL, a recent study showed that GPs were more hesitant to engage in ACP with patients who were still being treated by specialists in hospital, as these patients are often less open to discussion 33. Numerous initiatives have been developed to make earlier integration of specialised palliative care services a reality 34–37.…”

How do hospital-based nurses and physicians identify the palliative phase in their patients and what difficulties exist? A qualitative interview study

“…When and whether identification occurs seems to be highly dependent on a patient's diagnosis [18]. Whereas prognostication and the weighting of treatment options is a clear transition point to the palliative phase in cancer patients, in non-cancer patients, prognostication is considered more difficult which was also found within the primary care setting [16,17,32,33]. In patients with organ failure, so-called 'prognostic paralysis' can occur, where, because of the uncertainty in prognosis, physicians do not tell patients they have reached the end stage of their disease and do not plan appropriate care [34,35].…”

“…However, only a few physicians in our study described consulting with patients' GPs. GPs themselves experience this lack of collaboration as an important barrier to improving care for patients at the end of life [33,43].…”