BACKGROUND: The doctor-patient relationship has evolved to respect "the autonomy and patients' rights". One of the cornerstones in such autonomy is the opportunity for patients to draw living wills, also known as advance directives (AD). However, information about AD available to patients remains scarce largely due to the lack of involvement of General practitioners for several reasons. The aim of our study was to evaluate current general practitioner residents' (GPR) behavior concerning their role in informing their patients about AD.
METHOD: We built a French nationwide survey from GPR class of 2012 to 2014.
RESULTS: Two thousand three hundred ten residents completed our survey (21.1% of the total population of GPR during the period). 89.8% declared their willingness to offer patients the opportunity of writing AD. When asked about the usefulness of AD, 73.6% of residents responded that these are a suitable help for patients, but 19.7% considered that AD are essentially geared towards frail patients. Among residents who want to inform patients about AD (n = 2075), 14.7% wanted to involve all patients. Only 20.5% thought that elderly people should be systematically informed about AD. When the question involves other frail people in various disease areas, information seems relevant for 60.1% of GPR considering patient with cancer or malignant hematologic disease and for 56.2% about patients affected by neurodegenerative disease. When considering the routine use of AD, 20.5% of GPR would take them into account only if they are in agreement with the patient’s decision.
CONCLUSIONS: The results of the survey indicate that GPR would rather choose to decide who should be informed about AD, and when to take AD into account for ethical concerns.
BACKGROUND: The implementation of early palliative care within a primary care setting is a recent academic topic. Recruiting General Practitioners (GPs) to participate in a palliative care study can be challenging. The pro-Spinoza project implemented a Care Pathway for Primary Palliative Care in 5 areas in Belgium. During this project, the feasibility of the recruitment of GPs and palliative care patients was evaluated.
METHODS: The recruitment process was recorded in detail via an electronic logbook combining quantitative and qualitative data. Quantitative recordings included the contact types and the number of contacts with eligible GPs and were analysed descriptively. Qualitative recordings included field notes with feedback from the GPs and other stakeholders and were thematically analysed starting from the Grol and Wensing framework for professional behaviour change.
RESULTS: Of 4065 eligible GPs working in 5 areas under research, 787 GPs (19%) were contacted individually, 398 GPs (9,8%) were contacted face-to-face and most of these 398 GPs showed high interest in the topic. 112 GPs (2,8%) signed the collaboration agreement, but finally only 65 GPs (1,6%) delivered at least a completed baseline-questionnaire. Despite the initial interest in participating, the unpredictable and busy daily workloads of the GPs, as well as inexperience with research protocols, impeded the ability of the GPs to fully engage in the study. This resulted in the high dropout rate. Participating GPs reported that they had underestimated the effort required to effectively participate in the project.
CONCLUSIONS: Recruitment of GPs to palliative care research is challenging. Primary care is a vital service to engage in palliative care research however the practical limitations reduce the ability of the service to effectively engage in the research. More research is needed to determine how GPs might be better supported in research.
Music is one of the things in my life that has most reliably gotten me into and kept me out of trouble. Having played in bands for decades, I see parallels with the practice of medicine. As a hospitalist and a palliative care pediatrician, I would like to apply lessons from music to consider how general palliative care (provided by all clinicians) and specialty palliative care (provided by board-certified physicians) can work together in harmony. Music (like medicine) thrives through collaboration, benefits from specialized knowledge, and begs to be shared.
[Début de l'article]
Introduction: Primary care has a central role in palliative and end of life care: 45.6% of deaths in England and Wales occur under the care of primary care teams at home or in care homes. The Community Care Pathways at the End of Life (CAPE) study investigated primary care provided for patients in the final 6 months of life. This paper highlights the opportunities and challenges associated with primary palliative care research in the UK, describing the methodological, ethical, logistical and gatekeeping challenges encountered in the CAPE study and how these were addressed.
The study methods: Using a mixed-methods approach, quantitative data were extracted from the general practitioner (GP) and district nurse (DN) records of 400 recently deceased patients in 20 GP practices in the East of England. Focus groups were conducted with some GPs and DNs, and individual interviews held with bereaved carers and other GPs and DNs.
The challenges addressed Considerable difficulties were encountered with ethical permissions, with GP, DN and bereaved carer recruitment and both quantitative and qualitative data collection. These were overcome with flexibility of approach, perseverance of the research team and strong user group support. This enabled completion of the study which generated a unique primary palliative care data set.
Introduction : La HAS a créé en 2016 un document d'information et d'aide à la rédaction des directives anticipées. L'objectif était de répondre au manque de rédaction des directives anticipées depuis 2005, en lien avec un défaut d'information sur le dispositif. L'objet de notre étude était d'explorer les opinions et perceptions des médecins généralistes (MG) sur ce nouveau document, et comment ils pourraient l'intégrer dans leur pratique en soins primaires.
Méthodes : Étude qualitative par entretiens individuels semi-directifs réalisée auprès de 9 MG après échantillonnage raisonné et conduits jusqu'à saturation du recueil de données. Analyse thématique manuelle avec double codage croisé, dans une perspective phénoménologique. Résultats : Les MG jugent les documents pertinents, complets, mais complexes pour certains patients. Le manque de temps et la difficulté à parler de fin de vie sont perçus comme les freins principaux à l'utilisation de l'outil. Néanmoins les MG pensent qu'il permet d'aborder le sujet des directives anticipées auprès des patients et les amène à une réflexion sur leur fin de vie. Selon les médecins, la mise en place du dispositif nécessiterait d'être accompagné d'une information de la population et une formation des professionnels de santé.
Discussion : Les documents de la HAS sont complets et peuvent faciliter la rédaction des directives anticipées s'il y a une information de la population par les médias. Cela doit s'accompagner de la démocratisation de la discussion sur la fin de vie entre le patient et son médecin. Elle devra être initiée par le médecin.
Origine : BDSP. Notice produite par BIUSANTE 89AR0xCn. Diffusion soumise à autorisation
Notre travail s’appuie sur un constat : le médecin généraliste est désormais confronté à des patients atteints de pathologies longues et incurables, en phase de soins palliatifs. Or le généraliste n’est pas formé à leur prise en charge, différente de celle d’un autre patient : il ne s’agit plus d’aider sur le chemin de la guérison mais d’accompagner vers la mort.
Il s’agit donc de réfléchir à la posture du généraliste face à ce type de patient, lors d’un suivi au long cours. Quelles démarches doit-il adopter au sein du nouvel espace qu’est celui de la rencontre en soins palliatifs ?
Background: Identification of patients at the end-of-life is the first step in care planning and many general practices have Palliative Care Registers. There is evidence that these largely comprise patients with cancer diagnoses, but little is known about the identification process.
Objective: To explore the barriers that hinder GPs from identifying and registering patients on Palliative Care Registers.
Methods: An exploratory qualitative approach was undertaken using semi-structured interviews with GPs in South West England. GPs were asked about their experiences of identifying, registering and discussing end-of-life care with patients. Interviews were audio recorded, transcribed and analysed thematically.
Results: Most practices had a Palliative Care Register, which were mainly composed of patients with cancer. They reported identifying non-malignant patients at the end-of-life as challenging and were reluctant to include frail or elderly patients due to resource implications. GPs described rarely using prognostication tools to identify patients and conveyed that poor communication between secondary and primary care made prognostication difficult. GPs also detailed challenges around talking to patients about end-of-life care.
Conclusions: Palliative Care Registers are widely used by GPs for patients with malignant diagnoses, but seldom for other patients. The findings from our study suggest that this arises because GPs find prognosticating for patients with non-malignant disease more challenging. GPs would value better communication from secondary care, tools for prognostication and training in speaking with patients at the end-of-life enabling them to better identify non-malignant patients at the end-of-life.
Introduction: The provision of palliative end-of-life care (P/EOLc) for patients, wherever they live, is an increasingly important service, particularly given the increasing rates of cancer and other life-threatening diseases in Iran. However, unfortunately, those living in the rural areas of Iran are greatly disadvantaged with respect to this type of care. Therefore, the present study explored the feasibility of organizing P/EOLc in the rural areas of Iran.
Methods: In this qualitative study, two focus group (FG) discussions were held in Tabriz (Iran) with rural family physicians (FPs, n=23) and key P/EOLc stakeholders (n=13). The FG sessions were recorded, transcribed, and the transcriptions checked by participants before the data were subjected to content analysis.
Results: While most FPs indicated that they did not have sufficient involvement in providing P/EOLc, they emphasized the necessity of providing P/EOLc through four main themes and 25 subthemes. The four main themes were labeled as "structures and procedures," "health care provider teams," "obstacles," and "strategies or solutions." Furthermore, according to the main themes and subthemes identified here, the key stakeholders believed that the Iranian health system and the FPs' team have the potential to provide P/EOLc services in rural areas.
Conclusion: The most feasible strategy for providing P/EOLc in Iranian rural areas would be to use the current health care framework and base the process around the FP.
BACKGROUND: Although 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.
METHODS: Dutch GPs (N = 17) who had participated in a training on timely ACP were interviewed. Data from these interviews were analysed using direct content analysis.
RESULTS: Four 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.
CONCLUSIONS: ACP 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.
INTRODUCTION: While close collaboration between general practitioners (GPs) and hospital specialists is considered important, the sharing of care responsibilities between GPs and oncologists during palliative chemotherapy has not been clearly defined.
OBJECTIVE: Evaluate the opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.
DESIGN: We conducted semi-structured interviews using six hypothetical scenarios with purposively sampled GPs (n = 12) and oncologists (n = 10) in the Netherlands. Each represented an example of a clinical problem requiring different aspects of care: problems likely, or not, related to cancer or chemotherapy, need for decision support, and end-of-life care.
RESULTS: GPs and oncologists agreed that GPs should provide end-of-life care and that they should be involved in decisions about palliative chemotherapy; however, for the other scenarios most participants considered themselves the most appropriate provider of care. Themes that emerged regarding who would provide the best care for the patients in the different scenarios were expertise, continuity of care, accessibility of care, doctor-patient relationship, and communication. Most participants mentioned improved communication between the GP and oncologist as being essential for a better coordination and quality of care.
CONCLUSION: GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Findings raise awareness of the differences in reasoning and approaches and in current communication deficits between the two groups of health professionals. These findings could be used to improve coordination and collaboration and, ultimately, better patient care as results demonstrated that both disciplines can add value to the care for patients with advanced cancer. Key points This study identified contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy. Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication. Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care.
Objectif de lâ€™étude: Le médecin généraliste est un pivot de la prise en charge de la fin de vie à domicile. La dyspnée, symptôme fréquent à cette période est un facteur de souffrance et de stress pour le malade, les proches et les soignants. Lâ€™objectif de cette étude était de décrire sa prise en charge diagnostique et thérapeutique symptomatique en phase terminale à domicile par les médecins généralistes.
Méthode: Il sâ€™agit dâ€™une étude descriptive. Un questionnaire a été adressé par courrier postal aux 59 généralistes du nord des Landes.
Résultats: Vingt-neuf questionnaires ont été analysés (49 % de réponse). Les médecins ont déclaré principalement suivre leur malade avec le soutien de lâ€™infirmier à domicile seul (10 cas sur 27) ou dâ€™une structure dâ€™hospitalisation à domicile (7cas sur 27). Le principal symptôme recherché à lâ€™entretien médical était la sensation de manque dâ€™air (18 réponses 27). Lâ€™augmentation de la fréquence respiratoire (25 réponses sur 27) et la présence de signes de luttes (24 réponses sur 27) étaient les signes physiques les plus recherchés. Lâ€™échelle verbale simple était la plus utilisée (23 réponses sur 27). Parmi les thérapeutiques non médicamenteuses, le positionnement demi-assis du patient faisait lâ€™unanimité (27 réponses sur 27). Lâ€™association morphinique et anxiolytique était le traitement médicamenteux le plus utilisé (20 réponses sur 27). En cas dâ€™urgence, les 20 médecins confrontés à cette situation, ont informé les proches (17 réponses sur 20), utilisé lâ€™oxygène (16 réponses sur 20) et administré un traitement médicamenteux (17 réponses sur 20). La sédation était peu employée dans cette situation (4 réponses sur 20).
Conclusion: La majorité des médecins répondeurs diagnostiquaient la dyspnée par la sensation de manque dâ€™air et la présence de signes de lutte. Son évaluation se faisait par lâ€™échelle verbale simple et les traitements employés étaient le positionnement demi-assis du patient et lâ€™association de morphiniques et dâ€™anxiolytiques. Une étude précisant le sentiment des médecins, les molécules et les dosages des médicaments employés serait à envisager pour compléter les données recueillies.
BACKGROUND: Evidence regarding out-of-hours (OOH) community palliative care provision is required to inform the need for a 7-day work.
AIM: This paper seeks to provide evidence for this discussion by defining general practitioners' (GPs) OOH workload and patients' demographics, symptomology and interventions. By quantifying the challenges faced, we can understand current practice and focus on what provision is required.
DESIGN: Using Shropshire Doctors Co-operative's recorded data, the authors have collated a representative picture of the OOH GP palliative care practice over a year from 161 OOH GP-patient interactions.
SETTING: Primary care.
RESULTS: Palliative care makes up 11.4% of the total OOH GP home visits (HV). Overall 56% of OOH GP HVs are for patients who are expected to die within 48 hours, with 80% of the symptoms being agitation, secretions and pain. Overall 5.7% of OOH GP palliative HVs resulted in hospital admission; however, this decreased to 0.6% adjusting for the last 48-hour prognosis.
CONCLUSION: OOH Shropshire GPs deal with a wide variety of scenarios in a heterogeneous population. The greatest demand is from 17:00 to 00:00 (65% of the total shift) on weekdays, and from 09:00 to 00:00 on weekends (82% of the shift). These data begin to quantify the role being performed by OOH GPs, have implications for service provision and support 7-day work.
CONTEXT: Understanding the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying may allow general practitioners (GPs) to identify them, and initiate end-of-life discussions.
OBJECTIVES: This study aimed to investigate the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying, as determined by the Supportive and Palliative Care Indicators Tool (SPICT™).
METHODS: A multicenter cross-sectional observational study was conducted at 17 clinics with 22 GPs. We enrolled all patients aged =65 years who visited the GPs in March 2017. We used the Japanese version of the SPICT™ to identify patients being at risk of deteriorating and dying. We assessed the demographic and clinical characteristics of enrolled patients.
RESULTS: In total, 382 patients with a mean age of 77.4 ± 7.9 years were investigated. Sixty-six patients (17.3%) had =2 positive general indicators or =1 positive disease-specific indicator in the SPICT-JP. Patients with dementia/frailty, neurological disease, cancer, and kidney disease showed a significantly elevated risk of deteriorating and dying, while patients with other specific disease did not. The patients at risk were significantly older and less likely to be living with family at home. They also had a higher Charlson Comorbidity Index score and a lower Palliative Performance Scale score.
CONCLUSION: Among primary care outpatients aged over 65 years, 17.3% were at risk of deteriorating and dying regardless of their estimated survival time, and many outpatients at risk were not receiving optimal multidisciplinary care.
BACKGROUND: Generals practitioners (GPs) and district nurses (DNs) play a leading role in providing palliative care at home. Many services and facilities are available to support them in providing this complex care. This study aimed to examine the extent to which GPs and DNs involve these services, what their experiences are, and how involvement of these services and facilities can be improved.
METHODS: Sequential mixed methods consisting of an online questionnaire with structured and open questions completed by 108 GPs and 258 DNs, followed by three homogenous online focus groups with 8 GPs and 19 DNs, analyzed through open coding.
RESULTS: Most GPs reported that they sometimes or often involved palliative home care teams (99%), hospices (94%), and palliative care consultation services (93%). Most DNs reported sometimes or often involving volunteers (90%), hospices (88%), and spiritual caregivers (80%). The least involved services and facilities were psychologists and psychiatrists (51% and 50%) and social welfare (44% and 57%). Main reason for not involving services and facilities was 'not needing' them. If they had used them, most GPs and DNs (68-93%) reported solely positive experiences. Hardly anyone (0-3%) reported solely negative experiences with any of the services and the facilities. GPs and DNs suggested improvements in three areas: (1) establishment of local centers giving information on available services and facilities, (2) presentation of services and facilities in local multidisciplinary meetings, and (3) support organizations to proactively offer their facilities and services.
CONCLUSION: Psychological, social, and spiritual services are involved less often, suggesting that the classic care model, which focuses strongly on somatic issues, is still well entrenched. More familiarity with services that can provide additional care in these areas, regarding their availability and their added value, could improve the quality of life for patients and relatives at the end of life.
OBJECTIVES: General practitioners (GPs) are well placed to be involved in end-of-life care for patients with life-limiting illnesses. However, differing views exist regarding their role. This study aims to explore the views of GPs and specialist palliative care clinicians (SPCCs) on the role that GPs should play in the planning and provision of end-of-life care and important barriers and facilitators to GPs' involvement in end-of-life care including suggestions for improvement.
METHODS: Qualitative description methodology using semistructured interviews of 11 GPs and 10 SPCCs.
RESULTS: The participants identified two key roles that GPs should play in the planning and provision of end-of-life care: care planning and referring to palliative care services and being the primary clinician in charge of patient care. GPs and SPCCs expressed similar views; however, a significant proportion of the GP participants were not actively involved in end-of-life care. Factors affecting GPs' involvement in end-of-life care included: (1) GP and practice factors including continuity of care, long-term relationships with patients, knowledge and skills in end-of-life care, resource limitations and work patterns; (2) communication and collaboration between GPs and the acute healthcare system and (3) communication and collaboration between GPs and SPCCs.
CONCLUSION: GPs have a key role in the planning and provision of end-of-life care. GPs could be encouraged in this role by providing them with education and practical experience in end-of-life care, making changes to remuneration structure, formalised arrangements for shared care and encouraging continuity of care and developing long-term relationship with their patients.
BACKGROUND: Two representative samples of primary care physicians (N = 600) and medical oncologists (N = 300) in France were surveyed about their attitudes toward and knowledge about cancer pain management.
METHODS: The survey was conducted by telephone with a questionnaire based on a model developed by the University of Wisconsin-Madison Pain Research Group. It was designed to assess physicians' estimates of the prevalence of pain among patients with cancer, their practice in prescribing analgesics, their training in cancer pain management, and the quality of care received by cancer patients in their own practice and in France.
RESULTS: Barriers to adequate cancer pain management are prevalent and consistently more common among primary care physicians than among medical oncologists. Although 85% of primary care physicians and 93% of medical oncologists express satisfaction with their own ability to manage cancer pain, 76% of primary care physicians and 50% of medical oncologists report being reluctant to prescribe morphine for cancer pain. Both groups cite fear of side effects as their main reason to hesitate to prescribe morphine. Concerns about the risk of tolerance (odds ratio [OR], 1.15-2.52), perceptions that other effective drugs are available (OR, 1.11-2.41), perceptions that morphine has a poor image in public opinion (OR, 0.96-2.07), and the constraints of prescription forms (OR, 1.12-2.26) contribute significantly to physicians' infrequent prescription of morphine, as are being female (OR, 1.01-2.03) and being an older oncologist (OR, 1.09-2.51).
CONCLUSIONS: This study (1) confirms the existence among French physicians of attitudinal barriers and knowledge deficits previously reported in other countries that can impede cancer pain management, (2) identifies new barriers to the proper prescription of morphine for cancer pain control, and (3) reveals discrepancies in physicians' attitudes and knowledge about pain control which suggest a need for the systematic evaluation of cancer patients' care.
BACKGROUND:: Primary care physicians (PCPs) frequently have long-term relationships with patients as well as their families. As such they are well positioned to care for their patients at the end of their lives. As the number of patients in need of end-of-life care continues to grow, it is critical to understand how PCPs can fulfill that need. The purpose of our study is to perform a narrative review of the literature and develop a theoretical model delineating the overarching roles played by PCPs in caring for patients at the end of life.
METHODS:: For this narrative review, the authors searched Medline (PubMed), Embase, Cochrane Library, and Scopus up to March 22, 2017. Articles were not limited by geography.
RESULTS:: Review of existing literature generally supports 4 broad categories as the primary roles for PCP involvement in end of life: pain and symptom management; information management, including transmitting and clarifying information, setting care priorities, and assisting patients with treatment decisions; coordinating care and collaborating with other providers; and addressing patients' social, emotional, and spiritual needs.
CONCLUSIONS:: Based on the results of this review, PCPs provide a wide range of services to patients at the end of life. Promoting the provision of the full scope of services by PCPs will help ensure improved continuity of care while providing the highest quality of care for patients, both in the United States and around the world.
C'est dans le domaine institutionnel, en particulier hospitalier, dans la continuité de l'engagement de Cicely Saunders, dont 2018 marquera le centenaire de la naissance, que fut élaborée, pour continuellement évoluer depuis, une spécificité soignante de l'accompagnement de la fin de vie.
Etre accompagné pour mourir chez soi parmi les siens fut longtemps la norme, et si les soins et les traitements étaient parfois insuffisants, entourer, prendre soin et ne pas abandonner étaient la règle.
Aujourd'hui peu d'Equipes Mobiles de Soins Palliatifs (EMSP) sortent hors les murs et on assiste à un glissement du rôle des HAD (Hospitalisation A Domicile), de la prise en charge de situations médicales techniquement complexes, vers la prise en charge de plus en plus fréquente de situations de soins de support et accompagnement.
Le besoin des instances gestionnaires de l'Etat de contrôler les acteurs de terrain les a conduits à développer ce troisième secteur entre l'hôpital et le domicile, sans donner aux acteurs ambulatoires ou aux structures médico-sociales, les moyens nécessaires indispensables à un accompagnement de qualité, qui repose actuellement pour partie sur l'engagement "bénévole".
A domicile et en structures médico-sociales, les situations de fin de vie sont le plus souvent techniquement peu compliquées, et ce sont l'émergence et l'impact de l'isolement des personnes et de leurs difficultés socio-économiques, autant que les symptômes difficiles ou rebelles, qui conduisent à demander l'aide des EMSP ou HAD.
Etre bien soulagé à l'hôpital ne veyt pas nécessairement dire être bien accompagné. Etre bien entouré et accompagné chez soi ne veut pas nécessairement dire être bien sooulagé.
Ce colloque dont le thème est la fin de vie à domicile, à tous les âges de la vie, doit permettre un temps de rencontre entre les spécificités des soins palliatifs hospitaliers et les particularités, comme la culture, propres à l'accompagnement à la maison ou en structures médico-sociales. L'occasion d'une reconnaissance et d'échanges entre acteurs du domicile et hospitaliers : Sortir de l'entre-nous pour aller vers l'autre, chez l'autre, avec écoute, bienveillance et respect. Reconnaître nos complémentarités et nos limites respectives.
C'est pourquoi de nombreuses sessions insisteront sur des expériences partagées, y compris avec des proches aidants et des bénévoles d'accompagnement, pour montrer combien c'est ensemble et dans le respect de la place de chacun que nous oeuvrons au plus juste.
Dans le respect de la place de cet autre, chez lui, où nous sommes simplement de passage pour un moment fatidique du cours de son existence.
Parce que les soins palliatifs à domicile, c'est possible !
BACKGROUND: Pain management, especially at the end of life, varies depending on the prescriber's characteristics and attitudes. Little is known about the practices of general practitioners (GPs) regarding end-of-life management for patients with cancer.
OBJECTIVES: To provide an overview of the characteristics associated with GPs' attitudes and practices regarding opioids prescribing and to explore GPs' perceived role and difficulties in managing end-of-life care for patients with cancer.
DESIGN: A cross-sectional study (December 2015 to March 2016). Subjects and Analyses: Data were collected from a representative sample of 376 GPs in southeastern France recruited to participate in a survey on medical practices and opinions regarding cancer patient management. Descriptive analyses and multivariate logistic regressions were conducted to study the characteristics, attitudes, and practices associated with GPs' opioids prescribing attitudes.
RESULTS: Almost 97% of GPs stated that they prescribe opioids to end-of-life cancer patients. Among these, 77% said that they prescribe opioids on their own initiative, while 23% declared doing so in coordination with a specialist team. Female GPs, GPs working in solo practices, and GPs reporting more difficulties in managing end-of-life cancer patients were significantly less likely to prescribe opioids on their own initiative.
CONCLUSION: Our results suggest that GPs' characteristics and practices influence the prescribing attitudes at the end of life. Given the dearth of studies on this topic, further research is recommended to better understand the impact of GPs' characteristics on their prescriptive attitudes. The possible interactions between patients' and physicians' characteristics-in particular gender-should also be investigated.
Introduction: Choisir de mourir chez soi est une décision complexe et mobilise de nombreux acteurs de soins. Dans la continuité du Plan triennal 2015â€“2018 qui consacre un axe dâ€™intervention au déploiement des soins palliatifs à domicile, lâ€™équipe mobile de soins palliatifs (EMSP) stéphanoise souhaite intensifier le soutien aux soignants et aux aidants en ville. Cet article a pour objectif de mettre en évidence lâ€™intérêt de développer une activité à domicile auprès des patients et des professionnels de santé de ville.
Méthodes: Étude préliminaire, qualitative, observationnelle de 3 EMSP de la région Auvergne-Rhône-Alpes, de leurs actions à domicile et dâ€™un choix de consultations marquantes.
Résultats: Sur lâ€™ensemble des interventions physiques, le domicile représente entre 14 % et 25 % de lâ€™activité des EMSP1&2. Lâ€™EMSP3 a réalisé 313 visites en 2016. Ces équipes sollicitées par les hôpitaux et les médecins traitants interviennent pour des problèmes éthiques, de douleur, ou autres symptômes dâ€™inconfort, pour un soutien psychologique du patient, des aidants, ou des soignants libéraux, pour un besoin social ou une évaluation globale et pluridisciplinaire.
Conclusion: Lâ€™EMSP joue un rôle interstitiel fondamental cimentant un bricolage dâ€™acteurs multiples, motivés, mais parfois aussi souffrants ou maladroits autour dâ€™un malade en fin de vie à domicile. Véritable soutien pour le médecin généraliste et maillon entre la ville et lâ€™hôpital, elle essaye de respecter lâ€™intimité des familles, les choix des patients et le professionnalisme des soignants. Ces consultations complexes demandent du temps, de la disponibilité, de lâ€™expérience, et exigent une approche transdisciplinaire.