Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care.

BACKGROUND: The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services. OBJECTIVE: What are the challenges for GPs in caring for frail older patients at the end of their lives? MATERIAL AND METHODS: A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory. RESULTS: The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines. CONCLUSION: In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.

Primary palliative Care in General Practice - study protocol of a three-stage mixed-methods organizational health services research study.

BACKGROUND: The focus of this project is on improving the provision of primary palliative care (PC) by general practitioners (GPs). While approximately 10-15% of the incurable, seriously ill or dying people will be in need of specialist PC, the vast majority can be adequately treated within generalist care. The strengthening of the GP's role in PC, as well as ensuring close collaboration between specialist PC services and GPs have been identified as top priorities for the improvement of PC in Germany. Despite healthcare policy actions, diverse obstacles still exist to successful implementation of primary PC on a structural, process, and economic level. Therefore, this project aims at addressing barriers and facilitators to primary PC delivery in general practice in Germany. METHODS: The study follows a three-step approach; first, it aims at systematically analyzing barriers and facilitators to primary PC provision by GPs. Second, based on these outcomes, a tailored intervention package will be developed to enhance the provision of primary PC by GPs. Third, the intervention package will be implemented and evaluated in practice. The expected outcome will be an evidence-based model for successful implementation of primary PC delivery tailored to the German healthcare system, followed by a strategic action plan on how to improve current practice both on a local level and nationally. DISCUSSION: The first step of the project has been partly completed at the time of writing. The chosen methodologies of four sub-projects within this first step have opened up different advantages and disadvantages for the data collection. In sum of all sub-projects, the different methodologies and target groups contributed valuable information to the systematic analysis of barriers and facilitators to primary PC provision by GPs. TRIAL REGISTRATION: The study (BMBF-FK 01 GY 1610) was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00011821 ; date of registration: December 04th 2017) and at the German Register of health care research (Versorgungsforschung Deutschland - Datenbank) (Registration N° VfD_ALLPRAX_16_003817 ; date of registration: March 30th 2017).

What do positive and negative experiences of patients, relatives, general practitioners, medical assistants, and nurses tell us about barriers and supporting factors in outpatient palliative care? A critical incident interview study.

Background: The strengthening of the general practitioners' (GPs') role in palliative care (PC) has been identified as a top priority in order to improve PC in Germany. This study aims at exploring positive and negative experiences in PC in Germany from the perspectives of patients, relatives, and health care professionals in a primary care setting. Methods: Between March 2017 and August 2017, a total of 16 interviews with patients, relatives, GPs, medical assistants, and nurses were conducted. The Critical Incident Technique (CIT) was used to explore factors that influence excellent versus undesirable events in PC provision. Two researchers independently defined and counted critical incidents (CIs) from interview transcripts, performed a thematic analysis, and clustered the CIs into dimensions. Results: In summary, 16 interviews contained 280 CIs, divided into 130 positive and 150 negative CIs. The thematic analysis resulted in seven content domains, with each including positive and negative CIs, respectively: 1) way of care provision, 2) availability of care providers, structures, medication, and aids, 3) general formal conditions of care provision, 4) bureaucracy, 5) working practices in health care teams, 6) quality and outcome of care provision, and 7) communication. Conclusions: The results raise awareness for the aspects that lead to successful or undesirable PC experiences, observed from different perspectives. They open up the potential for primary PC improvement. Future research will facilitate development and implementation of more tailored interventions in order to improve generalists' PC.

[Primary palliative care provision by general practitioners: Development of strategies to improve structural, legal and financial framework conditions]. / Allgemeine Palliativversorgung in der hausärztlichen Praxis: Entwicklung von Strategien zur Verbesserung struktureller, rechtlicher und finanzieller Rahmenbedingungen.

INTRODUCTION: General practitioners (GPs) make a major contribution to outpatient palliative care (AAPV). In 2013, new fee rates for AAPV were included in the uniform assessment standard, which strengthens the financial framework conditions for outpatient palliative care by GPs. The aim of the ALLPRAX project is to improve the framework conditions for AAPV. This contribution focusses on ideas for changing structural, legal, and financial framework conditions for an optimised AAPV. METHODS: In April 2018, 28 healthcare professionals (10 GPs, 3 medical assistants, 3 hospital doctors, and 12 representatives of the nursing professions) from hospice and palliative care providers in Lower Saxony were invited to participate in nine group discussions at Hannover Medical School. During these group discussions, inhibitory factors for AAPV and possible solutions were discussed. The analysis of the group discussions was carried out using a summarizing content analysis according to Mayring. RESULTS: In order to optimise palliative care by GPs in Germany, it is proposed that a) additional palliative care specialists for care coordination and round-the-clock availability for patients and relatives in GP practices should be provided (structural solution), b) nursing staff should be permitted to prescribe aids (legal solution), and c) higher remuneration for medical consultations should be provided (financial solution). These approaches could increase feasibility in day-to-day practice and create incentives for caregivers to provide more high-quality general outpatient palliative care. DISCUSSION: The described high expenditure in general outpatient palliative care, which is hardly inferior to specialised outpatient palliative care from the caregivers' point of view, is not reflected accordingly, neither structurally nor financially. CONCLUSION: In order to optimise general outpatient palliative care, structural, legal and financial framework conditions need to be correspondingly adapted.