[Speaking and deciding with a serious illness]. / Sprechen und Entscheiden bei schwerer Erkrankung.

INTRODUCTION: It is a GP's task to identify patients as palliative patients at an early stage using suitable instruments. As part of a multidimensional basic assessment, the needs and expectations of the patient and their loved ones are recorded. During the interview, open questions are cla-rified, concerns are addressed and treatment options are discussed; a treatment goal is then jointly developed. Based on this treatment goal, an advance care plan is drawn up in consultation with the advising specialist and, if possible, with the involvement of a trusted person. The treatment goal, decisions and measures to be taken in an emergency are recorded in appropriate documents, which also serve to coordinate and communicate between persons involved in treatment.

[Palliative Care im Migrationskontext]. / Palliative Care im Migrationskontext.

INTRODUCTION: Palliative care in the migration context is mainly a diversity-sensitive treatment and care tailored to the individual person. In the case of serious advanced illness and especially at the end of life, people with a migration background have fundamentally similar basic needs as the rest of the population. They want to be as free as possible from pain and other distressing symptoms, and in the process of dying they want encouragement through their relatives and support from competent and committed health professionals with whom they can communicate in their native language whenever possible. A certain transcultural competence and experience in the care of people with a migration background makes it easier to understand values, wishes, but also worries and fears of the patients and their relatives and to meet their needs. The determining factor here is often not the cultural background from which they come, but their life and migration history, their education, their socioeconomic status and their position and role within the social environment. Discussions about the nature and prognosis of a serious illness should always be held with the affected person himself. Only if these discussions and the decision-making authority are delegated by the patient to a family member, indirect communication can be considered, whereby care must be taken to ensure that decisions are made in the interests of the patient and not the person making the decision by proxy.

[Early recognition or screening of dementia in general practice]. / Früherkennung oder Screening von Demenzerkrankungen in der hausärztlichen Praxis.

Early recognition or screening of dementia in general practice Abstract. General practitioners play a key role in timely dementia diagnosis. In view that there are currently no drugs to prevent the progression of dementia or are effective in patients with mild cognitive impairment, a general screening of older people to recognize pre-symptomatic stages of dementia is not recommended. Crucial for a timely diagnosis is the GP's perception of warning signs, so-called "red flags". If the patients, family members, authorities or even the GP notice even discreet signs of a possible early dementia, a neuropsychological and medical evaluation should be initiated. Personal history, history by informant, a physical examination, supplemented by a GP's psychiatric evaluation and ideally the careful assessment with the MoCA form the basis of a preliminary clarification in general practice. If dementia is suspected, this clarification should be supplemented by an in-depth laboratory examination and, if applicable, neuroimaging before the patient is referred, depending on the findings, to a memory clinic or a consultant specialist to confirm the diagnosis and if appropriate initiate pharmacological and non-pharmacological therapies.

Advance Care Planning for People with Dementia: The Role of General Practitioners.

General practitioners (GPs) play a key role in the timely diagnosis of dementia and also in advance care planning (ACP). They often have known patients and their families for decades and are familiar with their values and treatment preferences; they are, therefore, in a position to initiate the ACP process even before the appearance of the first symptoms of dementia and certainly following disclosure of the diagnosis. To do so, they should recognise whether patients are receptive to an ACP consultation or whether they might reject it for personal, social or cultural reasons. Under no circumstances should the patient or their family be coerced into making these provisions. In most countries, the current framework does not provide enough time and money for GPs to carry out actual ACP consultations completely on their own. There is evidence that specially trained health professionals are able to more effectively discuss treatment goals and limits of life-prolonging measures than GPs who are well acquainted with their patients. Consequently, we suggest that it will be the GPs' task to seize the right moment for starting an ACP process, to raise awareness of patients and their relatives about ACP, to test the patient's decision-making capacity and, finally, to involve appropriately trained healthcare professionals in the actual ACP consultation process. Care should be taken that these professionals delivering time-intensive ACP consultations are not only able to reflect on the patient's values but are also familiar with the course of the disease, the expected complications and the decisions that can be anticipated. The GP will ensure an active exchange with the ACP professional and should have access to the documentation drawn up in the ACP consultation process (treatment plan and advance directive including instructions for medical emergencies) as soon as possible. GPs as coordinators of healthcare provision should document appropriately all specialists involved in the care and ensure that treatment decisions are implemented in accordance with the patient's preferences for future care or the presumed will of the patient.

Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective.

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults' DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980's, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

General practitioners' attitudes towards early diagnosis of dementia: a cross-sectional survey.

BACKGROUND: Dementia is often underdiagnosed in general practice, which may be based on general practitioners' (GPs') knowledge and emotional factors as well as external problems. This study aimed to describe GPs' attitudes toward early diagnosis of dementia. METHODS: Cross-sectional postal survey in Switzerland in 2017. Members of the Swiss Association of General Practitioners (N = 4460) were asked to participate in the survey. The questionnaire assessed attitudes, enablers and barriers to early dementia diagnosis and post-diagnostic intervention strategies. Exploratory factor analysis and linear regression were used. RESULTS: The survey response rate was 21%. 85% of GPs agreed with enablers of early dementia recognition (e.g. "Plan for the future, organize support and care", "Minimize the strain and insecurity of patients and their informal family caregivers"). On the other hand, 15% of respondents perceived barriers towards early dementia recognition (e.g. "Time constraints in carrying out the necessary procedures to diagnose dementia"). GPs who were more likely to agree with barriers would less often counsel family members (ß = - 0.05, 95% CI = - 0.09 - -0.02) or test fitness to drive (ß = - 0.05, 95% CI = - 0.09 - -0.02), and more often choose a watchful waiting strategy (ß = 0.05, 95% CI = 0.02-0.09). CONCLUSIONS: The attitude of the majority of GPs is not characterized by diagnostic and therapeutic nihilism. However, negative attitudes were associated with sub-optimal management after the diagnosis. Thus, health systems are required to critically examine the use of available resources allowing GPs to look after patients and their relatives in a holistic way.

"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.

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.

[Trauma Disorders - A Relevant Health Problem]. / Traumafolgestörungen ­ ein relevantes Gesundheitsproblem.

Trauma Disorders - A Relevant Health Problem Abstract. In medical practice traumatic stress disorders are underdiagnosed. Post-traumatic stress disorder (PTSD) must be considered in case of pronounced need for control, severe anxiety and restlessness, jumpiness, mental torpor, dissociative disorders, social withdrawal, distrust or vegetative over-arousal. Simple screening instruments such as the "Primary Care PTSD Screen" are suitable for an initial assessment. As long as symptoms are not serious and long-lasting and there are no risk factors for the development of severe PTSD, it is a matter of creating external and internal security, informing about possible support, acknowledging the suffering and establishing secure interpersonal relationships. In the case of a pronounced PTSD with considerable psychological strain, a referral for further psychiatric or psychotherapeutic clarification and treatment is appropriate.

[High-quality hospital discharge summaries - general practitioners expectations]. / Welche Anforderungen stellt der Hausarzt an einen guten Spitalaustrittsbericht?

Hospital discharge summaries ensure treatment continuity after hospital discharge. In Switzerland discharge letters are a celebrated custom and a tool for training young colleagues. The primary purpose is to guarantee high-quality care of patients treated by hospital staff and general practitioners. From the perspective of the patient's general practitioner discharge summaries should convey current and accurate medically important patient data to the physician responsible for follow-up care. In the era of highly developed electronic data transfer and introduction of diagnose related groups (DRGs), it will be necessary to transmit hospital discharge information selectively to different target groups. Nevertheless data protection and medical secret must be complied with.

Roadmap for the treatment of heart failure patients after hospital discharge: an interdisciplinary consensus paper.

The transition period from the hospital to the outpatient setting is a critical phase when managing heart failure. A well-structured transition is paramount and helps to ensure a tight follow-up schedule for the heart failure patient, thereby improving treatment outcomes. This article aims to provide guidance for the first three follow-up visits after hospital discharge, with a focus on monitoring heart failure patients and up-titrating their medication in primary care.

One-on-one long-term tutorials in general practitioners' practices - a successful new teaching concept in primary care medicine.

To improve teaching in practical and communicative skills and knowledge in day-to-day medical practice, in 1997 we introduced one-on-one tutorials in general practitioners' offices as a mandatory part of medical students' academic education. Students participate actively half a day per week in their 3rd and 4th academic years (out of 6) in the office or clinic of a trained personal tutor. We recruited 270 general practitioners in town or from surrounding rural areas for this purpose. 85% of students choose general practitioners as their tutors and 15 % tutors in hospitals. To test whether the tutorials' aims were achieved, in 2005 we performed a detailed questionnaire evaluation after seven years' experience of one-on-one tutorials. All 236 students involved were asked to participate. The response rate was almost complete (98%). 233 anonymous questionnaires were analysed. Students reported improvement in knowledge, social and communicative skills and personal motivation. The overall rating of the one-on-one tutorials obtained 5.3 on a 6 point scale and achieved the top ranking among all university medical faculty classes. In-practice long-term one-on-one medical student-general practitioner tutorials can be recommended for implementation.

[Fatigue - a Common Symptom in General Practice]. / Müdigkeit ­ ein häufiges Symptom in der Hausarztpraxis.

Fatigue - a Common Symptom in General Practice Abstract. When patients suffering from fatigue consult a GP surgery, GPs should understand what patients mean by fatigue, how strongly they are affected in everyday life and how they themselves explain the symptom. In a next step, dangerous diseases such as depression, addiction or sleep apnea syndrome must be excluded. The main somatic and psychiatric causes of fatigue should be explored simultaneously with a more in-depth history. A simple physical exam and a few lab examinations are sufficient to capture the major disorders that present with the isolated symptom of fatigue. For further care, a primary biopsychosocial approach with a viable physician-patient relationship is crucial. Rough conclusions based on laboratory findings should be avoided; comorbidities must be considered.

Early diagnosis and management of dementia in general practice - how do Swiss GPs meet the challenge?

INTRODUCTION: In general practice, the diagnosis of dementia is often delayed. Therefore, the Swiss National Dementia Strategy 2014 concluded that action was needed to improve patient care. Little is known about GPs’ confidence in and approach to the diagnosis, disclosure and post-diagnostic management of individuals with dementia in Switzerland. The aim of this survey is to assess these elements of dementia care and GPs’ views on the adequacy of health care services regarding dementia. MATERIALS AND METHODS: Cross-sectional postal survey in Switzerland in 2017 supported by all academic institutes of general practice in Swiss universities. Members of the Swiss Association of General Practitioners (n = 4460) were asked to participate in the survey. In addition to the GPs’ demographic characteristics, the survey addressed the following issues: GPs’ views on the adequacy of health care services, clinical approach and confidence in the management of dementia. RESULTS: The survey response rate was 21%. The majority of GPs (64%) felt confident diagnosing dementia, but not in patients with a migration background (15%). For neuropsychological testing, three-quarters of GPs collaborated with memory clinics and were satisfied with the access to diagnostic services. At the time of first diagnosis, 62% of GPs diagnosed the majority of their patients with a mild stage of dementia, and 31% with a mild cognitive impairment. The most frequent actions taken by GPs after the diagnosis of mild dementia were giving advice to relatives (71%), testing fitness-to-drive (66%) and minimising cardiovascular risk factors (63%). While 65% of GPs felt confident taking care of patients with dementia, fewer (53%) felt confident in pharmacological treatment, coping with suicidal ideation (44%) or caring for patients with a migration background (16%). Half of GPs preferred to delegate the assessment of fitness-to-drive to an official authority. One in four GPs was not satisfied with the local provision of care and support facilities for patients with dementia. CONCLUSIONS: Overall, GPs reported confidence in establishing a diagnosis of dementia and sufficient access to diagnostic services. Post-diagnostic management primarily focused on counselling and harm reduction rather than pharmacological treatment. Future educational support for GPs should be developed, concentrating on coping with their patients’ suicidal ideation and caring for patients with a migration background.

Reasons for and Frequency of End-of-Life Hospital Admissions: General Practitioners' Perspective on Reducing End-of-Life Hospital Referrals.

BACKGROUND: Many palliative care patients are admitted to hospital shortly before death even though the acute hospital setting is not considered ideal for end-of-life care (EOLC). OBJECTIVES: This study aimed to evaluate General Practitioners' (GPs') perspective on the frequency of and reasons for hospital referrals of these patients. METHODS: Cross-sectional survey involving a stratified random sample of 2000 GPs in Switzerland in 2014. GP characteristics, frequency and type of end-of-life transfers, reasons for referrals, confidence in EOLC, and regional palliative care provision were assessed. Multivariate regression analysis was performed to identify the variables associated with frequency of hospital referrals at the end of life. RESULTS: The questionnaire was completed by 579 (31%) GPs. Frequent hospital referrals shortly before death were reported by 38%. GPs were less likely to report frequent hospitalizations when they felt confident in palliative care competencies, especially in anticipation of crisis. GPs were more likely to report frequent hospitalizations as being due to relatives' wishes, difficulties in symptom control, inadequate or absent care network, and the expense of palliative care at home. CONCLUSIONS: The results suggest that adequate support of and a care network for palliative patients and their caregivers are crucial for continuous home-based EOLC. Timely recognition of the advanced palliative phase as well as the involvement of well-trained GPs who feel confident in palliative care, together with adequate financial support for outpatient palliative care, might diminish the frequency of transitions shortly before death.

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.

Interprofessional Silence at the End of Life: Do Swiss General Practitioners and Hospital Physicians Sufficiently Share Information About Their Patients?

BACKGROUND: Empirical research suggests that the quality of patient care at the end of life (EOL) is influenced by the effectiveness of the collaboration between the general practitioners (GPs) and hospital physicians (HPs). AIM: To identify possible difficulties and barriers to effective collaboration at the EOL between GPs and HPs from the perspective of Swiss GPs. DESIGN: Twenty-three qualitative semi-structured interviews with GPs were transcribed and analyzed using Mayring's content analysis. Interdisciplinary clinical-ethical analysis focused on the quality of GP and HP professional collaboration. RESULTS: GPs described the quality of collaboration with HPs as poor, in particular the lack of communication. There were two main issues to emerge. First, infrequent communication with HPs could negatively affect the care of the patient. Second, GPs were concerned with the lack of information about hospital care and involvement in medical decision making given their longstanding relationships with their patients. CONCLUSIONS: The research showed that Swiss GPs were concerned with the quality of their patients' EOL care and the current level of GP/HP collaboration. GPs appealed for greater involvement with EOL care decisions based on their relationship of care and knowledge of patient preferences. These findings require further critical evaluation to explore the potential advantages for patient care. Existing evidence suggests that there are measurable health benefits from successful GP/HP collaborations. A change in the way GPs maintain involvement with their patients during hospitalizations would be warranted if it resulted in a better use of resources, better patient experiences, and better health outcomes.

Advance directives and the impact of timing. A qualitative study with Swiss general practitioners.

PRINCIPLES: Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners' perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments. METHODS: In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis. RESULTS: In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion. CONCLUSION: The distinct approaches, perspectives and rationales show that there is no well-defined or "right" moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.