Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada.

BACKGROUND: Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate clinicians' perceptions of the results. METHODS: We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team. RESULTS: Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results. CONCLUSIONS: This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement.

How do physicians and nurses in family practice describe their care for patients with progressive life-limiting illness? A qualitative study of a 'palliative approach'.

AIM: To explore how a palliative approach to care is operationalized in primary care, through the description of clinical practices used by primary care clinicians to identify and care for patients with progressive life-limiting illness (PLLI). BACKGROUND: Increasing numbers of people are living with PLLI but are often not recognized as needing a palliative approach to care. To meet growing needs, generalists such as family physicians will need to adopt a palliative approach to care in their own setting. Practical descriptions of a palliative approach in non-specialist settings have been lacking. METHODS: We conducted a qualitative descriptive study design using in-depth semi-structured interviews with 11 key informant participants (6 physicians, 3 nurse practitioners, 1 registered nurse, and 1 registered practical nurse) known to be providing comprehensive care to patients with PLLI in family practices in Ontario, Canada. We asked about their approach to identifying patients with PLLI and the strategies used in their care. We employed content analysis to develop themes. FINDINGS: Participants identified patients by functional decline, change in needs, increased acuity, and the specifics of a condition/diagnosis. Care strategies included concretizing commitment to care, eliciting goals of care, shifting care to the home, broadening team members including leveraging the support of family and community resources, and shifting to a 'proactive' approach involving increased follow-up, flexibility, and intensity. CONCLUSION: Primary care providers articulated strategies for identifying and providing care to patients with PLLI that illuminate an upstream approach tailored to their setting.