Systematic review of general practice end-of-life symptom control

Mitchell, G.; Senior, Hugh; Johnson, Claire; Fallon-Ferguson, Julia; Williams, Blair; Monterosso, Leanne; Rhee, Joel; McVey, Peta; Grant, Matthew; Aubin, Michèle; Nwachukwu, Harriet; Yates, Patsy

doi:10.1136/bmjspcare-2017-001374

Cited by 35 publications

(38 citation statements)

References 61 publications

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“…An interview-based study in 2006 noted that rural GPs in Western Australia (WA) perceived the provision of palliative care as a fundamental part of their role [18]. However, there are ongoing uncertainties around the scope and consistency of palliative and EOL care within general practice, including suboptimal symptom management [19][20][21], limited awareness of many patients' preferred place of death [22] and low prevalence of advance care planning in general practice [23].…”

Section: Introductionmentioning

confidence: 99%

End-of-life care in rural general practice: how best to support commitment and meet challenges?

et al. 2019

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Background: Few studies have specifically assessed the scope, nature and challenges of palliative and end-of-life care in rural general practice. These knowledge gaps limit the development of evidence-based policies and services for patients in the last months of life. This study aimed to explore the perspectives of general practitioners (GPs) and other stakeholders on rural GPs' involvement and challenges in providing palliative and end-of-life care in regional Australia. Methods: A qualitative study involving five focus groups with 26 GPs based in rural/regional Western Australia together with 15 individual telephone interviews with four GPs and 11 other stakeholders involved in end-of-life care across Australia. Results: The rural GPs' central role in end-of-life care was recognized by the majority of participants but multiple challenges were also identified. Some challenges were comparable to those found in urban settings but others were more pronounced, including resource limitations and lack of training. Inappropriate payment models discouraged GPs' involvement in some aspects of end-of-life care, such as case conferences and home visits. Compared to GPs in urban settings, those in rural/regional communities often reported closer doctor-patient relationships and better care integration and collaboration. These positive aspects of care could be further developed to enhance service provision. Our study highlighted the importance of regular interactions with other professionals and patients in providing end-of-life care, but many GPs and other stakeholders found such interactions more challenging than the more "technical" aspects of care. Conclusions: Rural/regional GPs appear to be disproportionately affected by inappropriate payment models and limited resources, but may benefit from closer doctor-patient relationships and better care integration and collaboration relative to urban GPs. Systematic collection of empirical data on GP management at end-of-life is required to build on these strengths and address the challenges.

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Section: Introductionmentioning

confidence: 99%

End-of-life care in rural general practice: how best to support commitment and meet challenges?

et al. 2019

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“…Our data provide the reason for encounter linked to GP's clinical management including the very small proportion who had symptomatic treatment of breathlessness. This may reflect previous reports of poor GP confidence in managing the symptom of breathlessness [26]. This study covers a period of clinical research where the evidence base for the symptomatic treatment of chronic breathlessness has evolved rapidly.…”

Section: Discussionmentioning

confidence: 68%

Breathlessness and opioid prescribing in COPD in general practice: a cross-sectional, observational study

et al. 2020

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Chronic breathlessness is a disabling syndrome, prevalent in people with advanced chronic obstructive pulmonary disease (COPD). Regular, low-dose, oral sustained-release morphine is approved in Australia to reduce symptomatic chronic breathlessness. We aimed to determine the current prescribing patterns of opioids for chronic breathlessness in COPD in Australian general practice and to define any associated patient and practitioner characteristics.Five years (2011 to 2016) of the Bettering the Evaluation and Care of Health database, an Australian national, continual, cross-sectional study of clinical care in general practice were used. The database included 100 consecutive clinical encounters from almost 1000 general practitioners annually (n=488 100 encounters). Descriptive analyses with subsequent regression models were generated.Breathlessness as a patient-defined reason for encounter was identified in 621 of 4522 encounters where COPD was managed. Opioids were prescribed in 309 of 4522 encounters where COPD was managed (6.8%; (95% CI) 6.1–7.6), of which only 17 were prescribed for breathlessness, and the rest for other conditions almost entirely related to pain. Patient age (45–64 years versus age 80+ years, OR 1.68; 1.19–2.36), Commonwealth Concession Card holders (OR 1.70; 1.23–2.34) and socioeconomic disadvantage (OR 1.30; 1.01–1.68) were associated with increased likelihood of opioid prescription at COPD encounters. The rate of opioid prescriptions rose over the 5 years of study.In primary care encounters for COPD, opioids were prescribed in 6.8% of cases, but almost never for breathlessness. These data create a baseline against which to compare changes in prescribing as the treatment of chronic breathlessness evolves.

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“…As the study design did not capture information on the patient, it remains uncertain how GPs identified a patient's medical need for SPHC. But as it is known that GPs' palliative care activities increase with experience [16], competence [36] and training [37]), we principally assume that GPs' ability to assess the medical need of SPHC improves with the extent of their engagement in palliative care. Against this background, we interpret our results that GPs who are not greatly engaged in palliative care activities involve SPHC as a substitution for PPC tasks they cannot or are not willing to provide themselves due to a lack of resources.…”

Section: Discussionmentioning

confidence: 99%

“…The single palliative care activity for which GPs most frequently deemed SPHC support beneficial was "technical and invasive treatment measures", such as morphine pumps, subcutaneous infusions and port systems, required to ensure sufficient symptom control. It is known that the wish to relieve patients' suffering [16], the non-availability of equipment [17] and low self-confidence in applying those measures [18] might lead GPs to seek support, especially with regard to therapeutic options [16,19]. Beyond that, specialist support in "treatment in the final phase" was attributed high importance.…”

Section: Main Findingmentioning

confidence: 99%

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

et al. 2020

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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.

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Systematic review of general practice end-of-life symptom control

Abstract: It is essential that GPs receive regular education and training, and exposure to EoLC from an early stage in their careers to ensure skill and confidence. Research into the role of GPNs in symptom control needs to occur.

Cited by 35 publications

References 61 publications

End-of-life care in rural general practice: how best to support commitment and meet challenges?

End-of-life care in rural general practice: how best to support commitment and meet challenges?

Breathlessness and opioid prescribing in COPD in general practice: a cross-sectional, observational study

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

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