ABSTRACT
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.
Subject(s)
Advance Care Planning , Dementia/therapy , General Practitioners , Decision Making , Humans , Physician-Patient RelationsABSTRACT
Nursing home residents are often referred by their general practitioners to the emergency department or to a geriatric hospital. Hospitalization is mainly perceived as a burden by elderly people; it may also contribute to a reduction of their mental abilities and functional decline. Reasons for admitting patients from nursing homes include infections, exacerbation of pre-existing cardiovascular disease and falls. GP presence in the nursing home, qualified nursing staff, early diagnosis of infections or acute on chronic episodes of e. g. heart failure and appropriate management of chronic diseases are essential to avoid unnecessary hospitalizations. Furthermore, physicians should identify palliative situations in a timely manner and should be familiar with the patients' preferences regarding hospitalization and place of death.
Les résidents des homes de soins sont souvent hospitalisés par leur médecin de famille dans un service d'urgence ou dans un hôpital gériatrique. Pour les personnes âgées, un séjour à l'hôpital est une grande charge souvent associée à une détérioration de leurs capacités mentales et de leurs compétences fonctionnelles. Les indications pour une hospitalisation des résidents de maisons de soins sont des infections, l'exacerbation de maladies cardiovasculaires préexistantes, et les conséquences de chutes. La disponibilité d'un médecin de famille dans l'home de soins, d'un personnel infirmier qualifié permettent le diagnostic des infections aiguës en temps opportun, la reconnaissance des exacerbations de maladies cardiaques préexistantes et la gestion appropriée des maladies chroniques indispensables pour empêcher des hospitalisations potentiellement évitables. Par ailleurs, le médecin de famille doit reconnaître les situations palliatives à temps et être informé sur les préférences de son patient en ce qui concerne le désir d'hospitalisation et le lieu du décès.