Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review

Abstract

BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood.ObjectiveTo provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 62 reviewed papers reported the GP’s and GPN’s role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC.ConclusionsWhile primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.

Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis

“…A UK 2001 report on OOH community palliative care identified challenges in service provision, communication, patient and carer support, and medical provision, including access to drugs, equipment, and specialist advice. 47 These issues are also echoed in international research on the challenges for home-based OOH end-of-life care provision 1 , 26 , 48 – 50 and explanations for unplanned hospital admissions for patients receiving end-of-life care. 51 – 53 In this context of difficult end-of-life care OOH provision, UK and international studies have identified hospital admissions to be an invaluable resource, readily available at all times of the day and night, and offering a safe solution to issues that may be difficult to resolve in the community at short notice.…”

“…These issues are also echoed in international research on the challenges for home-based OoH end-of-life care provision (1,26,(48)(49)(50) and explanations for unplanned hospital admissions for end-of-life care patients (51)(52)(53). In this context of difficult end-of-life care OoH provision, UK and international studies have identified hospital admissions to be an invaluable resource, readily available at all times of day and night and offering a safe solution to issues that may be difficult to resolve in the community at short notice (7,15).…”

Bolstering General Practitioner Palliative Care: A Critical Review of Support Provided by Australian Guidelines for Life-Limiting Chronic Conditions

“…This has important implications for the safety, quality and equity of care currently being provided by general practice. Although guidelines cannot resolve concerns with service delivery mechanisms and settings, as these will be influenced by numerous local and systemic factors, recognising these constraints is important given the evidence of GPs’ self-identified needs relating to palliative care [ 4 , 18 , 30 , 32 , 37 ]. The fact that these areas are not addressed across the guidelines analysed could be seen as a lost opportunity if non-specialist palliative care is deemed a policy priority and expectation and yet a significant proportion of GPs lack the confidence, education, or skills to provide it.…”

“…GPs worldwide cite similar barriers to providing palliative care for their patients such as system-level policies and processes that restrict consultation time and remuneration for more complex assessments or home visits [ 30 , 31 , 32 ]. Primary and secondary health care sector fragmentation has also created role uncertainty for GPs [ 15 , 26 , 33 , 34 ] and contributed to poor information flow between the various health professionals involved in care [ 27 , 35 ].…”

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

“…Furthermore, patients and family have described their expectations of optimal end-of-life care, which include therapeutic relationships with their general practitioner, effective communication, psychosocial support, symptom management and effective care coordination to achieve optimal end-of-life care (Johnson et al, 2020). However, a recent review found significant barriers for general practice (GP) teams in providing palliative and end-of-life care (Rhee et al, 2020).…”