24/10/12 How to account for diﬀerent prac6ce styles to inﬂuence primary pallia6ve care delivery Geoﬀ Mitchell University of Queensland ! The characteris6cs of GPs who DO and DO NOT prac6ce pallia6ve care Rhee et al J Pall Med 11: 980-‐985 Postal survey of Urban GPs in two areas of Sydney. 269 responses (61.9%) 1 24/10/12 Diﬀerent prac6ce styles Private general prac6ce – solo -‐small -‐large Corporate owned prac6ces. Proﬁt mo6ve removes all “low yield” condi6ons. Head oﬃce forbids involvement in case conference within consul6ng hours. 75% GPs willing to take on PC 25% don’t perform PC: Younger 48yrs vs 52yrs (p = 0.004) Part 6me 34 vs 41 hrs per wk (p<0.001) Overseas trained 41% vs 25% (p = 0.019) Employees rather than prac6ce principals 50% vs 13% (p<0.001) Female (trend) 52% vs 39% (p = 0.052) Source-‐ Rhee et al J Pall Med 11: 980-‐985. 2 24/10/12 Non-‐par=cipants-‐ barriers to providing PC (all signiﬁcant) Don’t do home visits 75% vs 55% Family commitments 72% vs 49% Personal commitments 68% vs 42% Lack of knowledge 48% vs 21% Emo6onal reasons 16% vs 11% Lack of interest 30% vs 9% Feel there is inadequate specialist support 70% vs 44% Catch 22 The more GPs do pallia6ve care, the more they feel comfortable with it (Lopez de Maturana Pall Med 1993) Length of GP experience predicts involvement in pallia6ve care (Hunt Aust Family Physician 1990) How to get GPs started in pallia=ve care, and how to keep them there? 3 24/10/12 Evidence for Stroke care planning Discharge planning -‐ Beler outcomes if nego6ated care plan developed between specialists and primary care services vs normal discharge care. – independent survival at 12 months . NNT=7 (Trondheim Stroke study-‐ Indredavik et al. Stroke 2000) BeFer Assessment, Support and Interdisciplinary Collabora=on (BASIC-‐PC) Hospital pa6ents iden6ﬁed nearing end of life Heart failure, Advanced lung disease Case conference to improve outcomes. PC specialist, specialist nurse, the pa6ent’s GP 4 24/10/12 Basic-‐PC Mul6-‐stage project 1.  Pilot individual pallia6ve care case conferences 2.  Develop search strategies in prac6ces 3.  Facilitate case conferences in prac6ces 4.  Implement communica6ons technology Assumed long-‐term outcome •  Beler care coordina6on between GPs and hospital. •  More care based at home. Clear role for GP and for nurses. •  Less hospitalisa6ons? OR same or more hospitalisa6ons – but earlier in exacerba6on’s course, shorter stay. 5 24/10/12 Phase 1 objec6ves Develop care plans involving the GP for heart failure and advanced lung disease pa6ents at the end of life –  Task alloca6on –  Improve communica6on between team members –  Case based learning Develop and evaluate a process for conduc6ng pallia6ve care case conferences –  Iden6fy barriers and enablers for case conferencing –  Develop understanding of medical specialist, nursing and allied health professionals’ percep6ons of pallia6ve care case conferencing. Iden6fy process for rou6ne case iden6ﬁca6on in the Australian GP sepng –  Develop poten6al strategies for pallia6ve care cases within their own prac6ce. –  Iden6fy common issues and misconcep6ons around the clinical care of these pa6ents GP characteris6cs (n=13) Age ≥60 4 50-‐59 3 40-‐49 4 30-‐39 0 <30 2 Overseas trained – 4 (Malaysia, India, South Africa, UK) Number doctors in prac6ce > 4 7 2-‐4 4 1 2 Home visits? Yes – 6 Phone advice – 5 No-‐ 2 6 24/10/12 7 24/10/12 Content of CC Core issues – physical, emo6onal issues of carer, out of hours arrangements Core beneﬁts – new knowledge for GPs, face to face mee6ng between GP and community nurse, speciﬁc tasks allocated to GP and community nurse Process issues Case conferences more easily driven from hospital side. One spontaneous CC from GP didn’t work – the external nurse did not know the pa6ent as well. Feedback from Dr – mostly posi6ve. Some felt they did not learn anything new, but appreciated the CC as a case review Some derived a lot of new informa6on, and a new oulook on end of life care 8 24/10/12 Case 1. Pa=ent – Female, Age 63. COPD, T2 diabetes, Chronic renal failure, good family support GP -‐ working in young area – ﬁrst pallia6ve care pa6ent Very good grasp of general medical principles of care. Used Locum service. Out of hours (OOH) arrangements: Health summary to be given to depu6sing service Give GP’s personal phone for advice OOH Emergency plan for dyspnoea-‐ have medica6on supplies and instruc6ons on hand at home Not for Resuscita6on leler for ambulance Nurse – follow-‐up on content of case conference Educate pa6ent on emergency plan 9 24/10/12 Case 2 Pa=ent – Female, age 67. Advanced pulmonary hypertension, CCF, dyspnoea and peripheral oedema, O2 dependent. Severe Rt knee pain requiring fentanyl patch. Lives alone. Currently in hospital for dyspnoea and early celluli6s. GP – overseas trained doctor, works in a corporate medical centre. Wary that pallia6ve care had been called in – may exacerbate anxiety Concerned about addic6on, respiratory suppression. Nurse – reported pa6ent despair at having to live like this for next few years. Issues discussed Importance of pallia6ve approach –hope for the best but plan for the worst. Educa6on on beneﬁts of opioids in dysponea, diﬀerence between medical dependency and addic6on – she is not an addict or likely to become one. Analysis of cause of pain – consider paracetamol, intra-‐ ar6cular steroid injec6ons to knee Pa6ent in existen6al distress + maybe depression – nurse to refer to hospital chaplain 10 24/10/12 Out of Hours plan Medical summary at home Not for resuscita6on leler at home GP oﬀered mobile number for consulta6ons OOH Advance Health Direc6ve in place Consider supervised independent living placement Summary Enormous range of clinical prac6ce scenarios Wide range of levels of clinical skills Encourage clinical skill enhancement GPs engaged and accep6ng of the process. Nurse involvement and prepara6on essen6al How to achieve this in some GP environments? 11