Klaus Bally

Management and outcome of severely elevated blood pressure in primary care A prospective observational study

OBJECTIVE In primary care the management of patients with acute severely elevated blood pressure (BP) is challenging. The aim of the study was to evaluate the initial management and outcome of patients presenting to their general practitioner (GP) with severe high blood pressure. METHODS Twenty five general practitioners prospectively identified 164 patients presenting with severely elevated blood pressure (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg). At baseline, patients were categorised as having a hypertensive emergency, urgency or asymptomatic BP elevation. The therapeutic approach of the GPs was assessed and patient outcome at 12 month follow-up was analysed. RESULTS Median age of 164 patents was 71 (range 22 to 97) years, 60 (37%) were male and 107 (65%) had pre-existing hypertension. Mean baseline systolic BP was 198 ± 16 (range 145 to 255) mm Hg, mean baseline diastolic BP was 101 ± 15 (range 60 to 130). In total, 99 (60%) of patients had asymptomatic BP elevation, 50 (31%) had hypertensive urgency, and 15 (9%) had a hypertensive emergency. Only around two thirds (61%) of patients were given immediate blood pressure lowering medication (most frequently calcium antagonists). Ten patients (6%) were immediately admitted to hospital. Systolic and diastolic BP declined significantly (p <0.01) between one and six hours after study inclusion (drop of systolic and diastolic BP, 24 ± 9 and 10 ± 1, respectively) and were significantly lower (p <0.01) at three month follow-up compared to the initial measurement (drop of systolic and diastolic BP, 37 ± 6 and 14 ± 4, respectively). On average systolic BP was still above target values after three months (148 ± 21). During 12 months of follow-up patients with hypertensive emergency, hypertensive urgency, and asymptomatic BP elevation experienced a cardiovascular event in 27% vs. 6% vs. 16%, of cases respectively (p = 0.17). CONCLUSION The majority of 164 patients who presented with acutely and severely elevated blood pressure (BP >180 +/or >110 mm Hg) to their GPs was asymptomatic, had pre-existing hypertension and was managed in GPs office unless a hypertensive emergency was present. At three month follow-up mean systolic BP was still above target values.

Discontinuation of secondary prevention medication after myocardial infarction - the role of general practitioners and patients.

BACKGROUND Despite the significant benefits of secondary prevention (SP) medication after acute myocardial infarction (MI), evidence suggests that these medications are neither consistently prescribed nor appropriately adhered to by patients. The aim of this study was to investigate the role of general practitioners (GPs) and patients regarding discontinuation of SP medication after MI and reasons for discontinuation. METHODS In this observational study, GPs of patients who had suffered acute MI provided information on discontinuation of SP medication 6 and 12 months after hospital discharge. A questionnaire-based approach was used (a) to assess the consistent use of SP medication after MI, (b) to determine reasons for stopping SP medication, (c) to quantify the involvement of GPs and patients regarding discontinuation, and (d) to analyse potential factors that are associated with discontinuation of medication. RESULTS Of 204 subjects 6 and 12 months after hospital discharge 83% and 75% patients, respectively, were still on recommended SP medication. Overall, one or more SP medications were stopped (53 medications) or modified (15 medications) in 52 (25%) patients. Adverse side effects were the main reason for stopping medication (63%). GPs reported being responsible for initiating discontinuation or modification more frequently than patients (62% vs 38%, p = 0.065). CONCLUSION The consistent use of evidence-based pharmacotherapy 6 and 12 months after myocardial infarction was adequate. Three out of four patients were still on recommended SP medication after 1 year of follow-up. Two-thirds of medication discontinuations were initiated by GPs, predominantly because of side effects.

“We need to talk!” Barriers to GPs’ communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study

GPs usually care for their patients for an extended period of time, therefore, requests to not only discontinue a patient’s treatment but to assist a patient in a suicide are likely to create intensely stressful situations for physicians. However, in order to ensure the best patient care possible, the competent communication about the option of physician assisted suicide (PAS) as well as the assessment of the origin and sincerity of the request are very important. This is especially true, since patients’ requests for PAS can also be an indicator for unmet needs or concerns. Twenty-three qualitative semi-structured interviews were conducted to in-depth explore this multifaceted, complex topic while enabling GPs to express possible difficulties when being asked for assistance. The analysis of the gathered data shows three main themes why GPs may find it difficult to professionally communicate about PAS: concerns for their own psychological well-being, conflicting personal values or their understanding of their professional role. In the discussion part of this paper we re-assess these different themes in order to ethically discuss and analyse how potential barriers to professional communication concerning PAS could be overcome.

General Practitioners' Attitudes towards Essential Competencies in End-of-Life Care: A Cross-Sectional Survey

Background Identifying essential competencies in end-of-life care, as well as general practitioners’ (GPs) confidence in these competencies, is essential to guide training and quality improvement efforts in this domain. Aim To determine which competencies in end-of-life care are considered important by GPs, to assess GPs’ confidence in these competencies in a European context and their reasons to refer terminally ill patients to a specialist. Design and Setting Cross-sectional postal survey involving a stratified random sample of 2000 GPs in Switzerland in 2014. Method Survey development was informed by a previous qualitative exploration of relevant end-of-life GP competencies. Main outcome measures were GPs’ assessment of the importance of and confidence in 18 attributes of end-of-life care competencies, and reasons for transferring care of terminally-ill patients to a specialist. GP characteristics associated with main outcome measures were tested using multivariate regression models. Results The response rate was 31%. Ninety-nine percent of GPs considered the recognition and treatment of pain as important, 86% felt confident about it. Few GPs felt confident in cultural (16%), spiritual (38%) and legal end-of-life competencies such as responding to patients seeking assisted suicide (35%) although more than half of the respondents regarded these competencies as important. Most frequent reasons to refer terminally ill patients to a specialist were lack of time (30%), better training of specialists (23%) and end-of-life care being incompatible with other duties (19%). In multiple regression analyses, confidence in end-of-life care was positively associated with GPs’ age, practice size, home visits and palliative training. Conclusions GPs considered non-somatic competencies (such as spiritual, cultural, ethical and legal aspects) nearly as important as pain and symptom control. Yet, few GPs felt confident in these non-somatic competencies. These findings should inform training and quality improvement efforts in this domain, in particular for younger, less experienced GPs.

The utility of standardized advance directives: the general practitioners’ perspective

Advance directives (AD) are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to (a) appoint a surrogate decision maker, and/or (b) to determine future medical treatments and/or (c) give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates (to appoint surrogate decision makers) and medium length templates with checkboxes to indicate patients’ preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients’ preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient’s general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease.

Caring for older people: is home care always best?

In 2007, the famous Swiss actress Lilo Pulver (well-known for the Billy Wilder film One, Two, Three ) decided to move into a residential home in Bern. At this time, she was neither disabled nor dependent on care, but rather wanted to share her memories and fears with other ageing people. Her decision could be seen as a significant starting point for a broader debate about how we would like to live in old age. At present the mantra seems to be that everyone should be looked after at home, although this is often socially and economically challenging. However, is the situation in a care home always worse than at home? Interestingly, Eisele and colleagues in this issue of the BJGP show that certain patient groups might profit from moving into an institution.1 Likewise, Penders and colleagues point out that residents of care homes in the Netherlands actually receive better palliative care from GPs than patients living at home.2 In addition, they found that people in their home environment face a higher risk of hospitalisation or transfers to other care institutions than older people in care homes. Such dislocations usually have a negative effect on the quality of life of older people. The question is, therefore, whether living in a home environment is …

Teil 3: Palliative Care

Seit uber 40 Jahren erarbeitet und veroffentlicht die Schweizerische Akademie der Medizinischen Wissenschaften (SAMW) medizin-ethische Richtlinien. Die Redaktion von Primary and Hospital Care hat es sich zur Aufgabe gemacht, in diesem Jahr in lockerer Folge den Inhalt einzelner SAMW-Richtlinien vorzustellen.

Patients âgés et fractures au niveau de la hanche

Si, apres une chute sur la hanche, le patient n’est plus capable de se deplacer en raison de douleurs et malgre l’absence de mise en evidence radiologique conventionnelle d’une fracture, il convient de pousser les examens afin d’arriver a un diagnostic. Procede de choix: l’imagerie par resonance magnetique (IRM).