Peter Pype

Are general practitioners prepared to end life on request in a country where euthanasia is legalised

Background In 2002, Belgium set a legal framework for euthanasia, whereby granting and performing euthanasia is entrusted entirely to physicians, and—as advised by Belgian Medical Deontology—in the context of a trusted patient–physician relationship. Euthanasia is, however, rarely practiced, so the average physician will not attain routine in this matter. Aim To explore how general practitioners in Flanders (Belgium) deal with euthanasia. This was performed via qualitative analysis of semistructured interviews with 52 general practitioners (GPs). Results Although GPs can understand a patients request for euthanasia, their own willingness to perform it is limited, based on their assumption that legal euthanasia equates to an injection that ends life abruptly. Their willingness to perform euthanasia is affected by the demanding nature of a patients request, by their views on what circumstances render euthanasia legitimate and by their own ability to inject a lethal dose. Several GPs prefer increasing opioid dosages and palliative sedation to a lethal injection, which they consider to fall outside the scope of euthanasia legislation. Conclusions Four attitudes can be identified: (1) willing to perform euthanasia; (2) only willing to perform as a last resort; (3) feeling incapable of performing; (4) refusing on principle. The situation where GPs have to consider the request and—if they grant it—to perform the act may result in arbitrary access to euthanasia for the patient. The possibility of installing transparent referral and support strategies for the GPs should be further examined. Further discussion is needed in the medical profession about the exact content of the euthanasia law.

Health care professionals' perceptions towards lifelong learning in palliative care for general practitioners: a focus group study.

BackgroundThere is a growing need for palliative care. The majority of palliative patients prefer their general practitioner (GP) to organize their palliative home care. General practitioners need a range of competences to perform this task. However, there has been no general description so far of how GPs keep these competences up-to-date. The present study explores current experiences, views and preferences towards training and education in palliative care among GPs, palliative home-care professionals and professionals from organizations who provide training and education.MethodsFive focus groups were brought together in Belgium, with a total of 29 participants, including members of the three categories mentioned above. They were analysed using a constant comparison method.ResultsThe analysis revealed that undergraduate education and continuing medical education (CME) while in practice, is insufficient to prepare GPs for their palliative work. Workplace learning (WPL) through collaboration with specialized palliative home-care nurses seems to be a valuable alternative.ConclusionsThe effectiveness of undergraduate education might be enhanced by adding practical experience. Providers of continuing medical education should look to organize interactive, practice-based and interprofessional sessions. Therefore, teachers need to be trained to run small group discussions. In order to optimize workplace learning, health care professionals should be trained to monitor each other’s practice and to provide effective feedback. Further research is needed to clarify which aspects of interprofessional teamwork (e.g. professional hierarchy, agreements on tasks and responsibilities) influence the effectiveness of workplace learning.

The Role of Communication

According to modern concepts, medical knowledge, communication skills, physical examination, and problem solving are four essential components of clinical competence of a physician. Communication and relationship have been demonstrated to have an impact on patients’ experience of care, to improve patients’ adherence to treatment regimens, clinical outcomes and quality, patient safety, teamwork, cultural sensitivity, and to reduce medical malpractice risk. Inter-professional communication between the various healthcare practitioners is another important aspect in the treatment of patients. Medicine is becoming a shared effort not only between the various healthcare practitioners involved in treatment but also the patients themselves. All parties involved would benefit from proper collaboration and communication. Appropriate communication is a cornerstone of modern medicine, where understanding and context-driven interview lead the way in improved patient experience. The medical interview is a complex process of taking information for the purpose of diagnosis, and it is an extremely important factor in establishing a relationship between doctors and patients. Integrated patient-centered and physician-centered interview builds a relationship, opens the discussion, gathers information, understands the patient’s perspective, shares information, reaches agreement, and provides closure. All these are essential elements of the medical interview. The person-centered medical interview is an important bridge between personalized and person-centered medicine. It is necessary to develop, evaluate, and implement training programs aimed at enhancing person-centerd communication and care.

Preparing palliative home care nurses to act as facilitators for physicians' learning: Evaluation of a training programme.

Background: Palliative care requires a multidisciplinary care team. General practitioners often ask specialised palliative home care teams for support. Working with specialised nurses offers learning opportunities, also called workplace learning. This can be enhanced by the presence of a learning facilitator. Objectives: To describe the development and evaluation of a training programme for nurses in primary care. The programme aimed to prepare palliative home care team nurses to act as facilitators for general practitioners’ workplace learning. Design: A one-group post-test only design (quantitative) and semi-structured interviews (qualitative) were used. Methods: A multifaceted train-the-trainer programme was designed. Evaluation was done through assignments with individual feedback, summative assessment through videotaped encounters with simulation-physicians and individual interviews after a period of practice implementation. Results: A total of 35 nurses followed the programme. The overall satisfaction was high. Homework assignments interfered with the practice workload but showed to be fundamental in translating theory into practice. Median score on the summative assessment was 7 out of 14 with range 1–13. Interviews revealed some aspects of the training (e.g. incident analysis) to be too difficult for implementation or to be in conflict with personal preferences (focus on patient care instead of facilitating general practitioners’ learning). Conclusion: Training palliative home care team nurses as facilitator of general practitioners’ workplace learning is a feasible but complex intervention. Personal characteristics, interpersonal relationships and contextual variables have to be taken into account. Training expert palliative care nurses to facilitate general practitioners’ workplace learning requires careful and individualised mentoring.

What, how and from whom do health care professionals learn during collaboration in palliative home care: a cross-sectional study in primary palliative care

BackgroundPalliative care often requires inter-professional collaboration, offering opportunities to learn from each other. General practitioners often collaborate with specialized palliative home care teams. This study seeks to identify what, how and from whom health care professionals learn during this collaboration.MethodsCross-sectional survey in Belgium. All palliative home care teams were invited to participate. General practitioners (n = 267) and palliative care nurses (n = 73) filled in questionnaires.ResultsGeneral practitioners (GPs) and palliative care nurses learned on all palliative care aspects. Different learning activities were used. Participants learned from all others involved in patient care. The professionals’ discipline influences the content, the way of learning and who learns from whom. Multiple linear regression shows significant but limited association of gender with amount of learning by GPs (M < F; p = 0.042; Adj R2 = 0.07) and nurses (M > F; p = 0.019; Adj R2 = 0.01).ConclusionsThis study is the first to reveal what, how and from whom learning occurs during collaboration in palliative care. Training professionals in sharing expertise during practice and in detecting and adequately responding to others’ learning needs, could optimize this way of learning.

The landscape of postgraduate education in palliative care for general practitioners: results of a nationwide survey in Flanders, Belgium.

OBJECTIVE To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GPs) towards CME. METHODS Questionnaire-survey among official providers of formal CME. RESULTS The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GPs concerning education in palliative care into account. CONCLUSIONS The present offer of CME is insufficient to educate GPs in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GPs and their patients in the cold. PRACTICE IMPLICATIONS A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GPs working together with specialized palliative home care teams.

Patients' nursing records revealing opportunities for interprofessional workplace learning in primary care: a chart review study

Background: Working and learning go hand in hand during interprofessional collaborative practice. Patients′ nursing records are designed to record patient care and health status. It is not known whether these records are also used to keep track of interprofessional contacts or interprofessional learning between team members. This study explored the usefulness of patients′ nursing records in optimising interprofessional workplace learning for general practitioners. Methods: We utilized a descriptive retrospective chart review. All palliative home care teams of the Dutch speaking part of Belgium were involved. Throughout the year 2010, a representative sample of patient charts was selected. Characteristics of encounters between general practitioners and palliative care nurses were extracted from the charts. Results: Detailed accounts of interprofessional contacts were found in the charts. Palliative care nurses recorded number and type of contacts, topics discussed during contacts and general practitioner′s learning activities. Discussion: Palliative care nurses are sensitive and open towards the general practitioners′ learning needs. Patients′ nursing records provide useful information for interprofessional team discussions on workplace learning. Healthcare professionals should be trained to respond to each other′s learning needs.

Comparing the use and timing of palliative care services in COPD and lung cancer: a population-based survey

Palliative care is a proven approach to enhance quality of life and care both for people with severe chronic obstructive pulmonary disease (COPD) [1] and those with lung cancer [2], and it is encouraged to start palliative care early in the disease trajectory [3, 4]. Similar symptoms occur in both diseases, such as pain, insomnia, fatigue, low mood and dyspnoea [5], with a study reporting even worse physical and emotional functioning for COPD than for lung cancer [6]. These symptoms signal palliative care needs [6], and require treatment focused on symptom management and psychosocial support for more than just the terminal phase. A high use of healthcare resources in COPD is found, related to a tendency towards aggressive and life-prolonging care [7]. Difficulties in predicting disease trajectories and unclear prognosis have been suggested as explanations for why people with COPD are referred less often for palliative care [8]. Palliative care services are used mainly as terminal care in lung cancer and COPD, with less and later use for COPD http://ow.ly/j38v30jxbhv

Having cancer in a foreign country

OBJECTIVES Although immigration and cancer care are two frequently discussed topics in healthcare, the combination of both has seldom been done. Little is known about how immigrant patients experience having cancer in a foreign country. The aim of the study is to gain deeper insight into the meaning of having cancer, in a foreign country and to identify the expectations and experiences of immigrant patients confronted with this disease. METHODS Thirty adult non-western immigrant cancer patients were interviewed by means of an in-depth interview technique. The technique of constant comparison, derived from the constructivist grounded theory, was used to analyze the data from the interviews. RESULTS Having cancer is a human experience, regardless of ones country of origin. Patients show universal reactions and reaction patterns when confronted with cancer and dealing with cancer treatment. Immigrant patients experience specific obstacles when dealing with cancer, of which the language barrier is the most important. A general lack of accurate basic knowledge about health and disease was found, making certain patients more vulnerable. CONCLUSIONS AND PRACTICE IMPLICATIONS When dealing with cancer, immigrant patients are confronted with two major obstacles: a language barrier and a lack of knowledge about health and disease. The implications for a better practice occur on three levels: empowering patients, training healthcare professionals and adapting policy.

'A palliative end-stage COPD patient does not exist' : a qualitative study of barriers to and facilitators for early integration of palliative home care for end-stage COPD

Early integration of palliative home care (PHC) might positively affect people with chronic obstructive pulmonary disease (COPD). However, PHC as a holistic approach is not well integrated in clinical practice at the end-stage COPD. General practitioners (GPs) and community nurses (CNs) are highly involved in primary and home care and could provide valuable perspectives about barriers to and facilitators for early integrated PHC in end-stage COPD. Three focus groups were organised with GPs (n = 28) and four with CNs (n = 28), transcribed verbatim and comparatively analysed. Barriers were related to the unpredictability of COPD, a lack of disease insight and resistance towards care of the patient, lack of cooperation and experience with PHC for professional caregivers, lack of education about early integrated PHC, insufficient continuity of care from hospital to home, and lack of communication about PHC between professional caregivers and with end-stage COPD patients. Facilitators were the use of trigger moments for early integrating PHC, such as after a hospital admission or when an end-stage COPD patient becomes oxygen-dependent or housebound, positive attitudes towards PHC in informal caregivers, more focus on early integration of PHC in professional caregivers’ education, implementing advance care planning in healthcare and PHC systems, and enhancing communication about care and PHC. The results provide insights for clinical practice and the development of key components for successful practice in a phase 0–2 Early Integration of PHC for end-stage COPD (EPIC) trial, such as improving care integration, patients’ disease insight and training PHC nurses in care for end-stage COPD.Chronic lung disease: Improving palliative careResearch in Belgium provides insights into the possible implementation of early palliative care (PC) for patients with chronic obstructive pulmonary disease (COPD). While many sufferers of end-stage COPD would benefit emotionally and physically from palliative home care in their final months, many only receive PC in their last few days. Charlotte Scheerens at End-of-life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB) and co-workers at Ghent University and Vrije Universiteit Brussel (VUB) conducted focus group discussions with 28 general practitioners and 28 community nurses to establish the main barriers to and facilitators for palliative home care implementation for end-stage COPD. Barriers included the unpredictability of the disease, lack of patient understanding of COPD, and complex communication issues between staff across primary care, hospitals and community settings. Identifying ‘triggers’ to implement PC—oxygen dependence, for example—and improving communication and understanding of COPD at all levels could facilitate early integration of palliative home care (PHC).